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Prior Approval Requirement Listing

Certain services, drugs and supllies require advance (prior) approval before benefits are provided. This ensures the procedures are diagnostically appropriate, medically necessary and cost effective.

In cases where prior approval is denied or not sought, you (the member) will have to pay the total charge for the services.

Procedures Requiring Prior Approval (PA)
Drugs Requiring Prior Approval (PA)

Procedures Requiring Prior Approval

Procedures listed and on the prior approval list will only have benefits provided if approval is obtained in advance.

Procedures requiring PA

Type of Procedure	What Requires Prior Approval
Out-of-network Providers or Facilities	All services
Ambulance	All air or water ambulance transport and non-emergent ground ambulance
Anesthesia for Colonoscopy or Endoscopy	All services
Capsule Endoscopy	All services
Chiropractic	Chiropractic care after initial 12 visits in a calendar year
Chondrocyte Transplants	All services
Continuous Glucose Monitoring (Outpatient)	Outpatient, 72-hour continuous glucose monitoring
Continuous Passive Motion (CPM) Equipment	All services
Dental	Dental services—oral surgery, trauma and orthognathic surgery. Exceptions are wisdom teeth extraction and oral lesion excision and biopsy
Durable Medical Equipment (DME)	Durable medical equipment with a purchase price over $250, including continuous positive airway pressure/bilevel positive airway pressure (CPAP/BIPAP) machines, vacuum-assisted closure of chronic wounds, external bone growth stimulators, oxygen and related supplies, nebulizers, hospital beds, wheelchairs and hospital-grade electric breast pumps (other than those provided through Better Beginnings®), compression stockings, high frequency chest wall oscillation system & supplies, insulin pumps & supplies and parenteral supplies. Click here for the DME Prior Approval form
Genetic Testing	Most tests—those with Health Care Procedure Coding System (HCPCS) Codes between S3800 and S3890
Home Infusion Therapy	All services
Hospice Care	All services
Hyperbaric Oxygen Therapy	All services
Medical Nutrition for Inherited Metabolic Disease	Medical supplies and pumps, enteral formulae and parenteral nutrition
Mental Health and Substance Abuse Treatment	All services. Some contracts waive Prior Approval, please see your Certificate of Coverage for specifics.
New Medical Procedures	New procedures still considered investigational or experimental
Orthotics	All orthotics with a purchase prices greater than $250 and some devices under $250
Osteochondral Autograft Transfer System (OATS)/Mosaicplasty	All services
Plastic and Cosmetic Procedures	All services except breast reconstruction for patients with a diagnosis of breast cancer.
Polysomnography (sleep studies) and Multiple Sleep Lateral Testing (MSLT)	All services
Prescription Drugs	Separate lists apply, please see Rx Center - Prior Approval Drug List
Private Duty Nursing	All services
Prosthetics	All, regardless of cost
Radiology Services	All services. Examples include CT, MRI, MRA, MRS, PET and nuclear cardiology. Providers will work with American Imaging Management (AIM).
Rehabilitation (cardiac/pulmonary/inpatient rehabilitation facility)	All services
Surgery	Certain surgical procedures including bariatric (obesity) surgery, gastric electrical stimulation, percutaneous vertebroplasty, vertebral augmentation, temporomandibular joint manipulation/surgery and anesthesia and tumor embolization.
Transcutaneous Electrical Nerve Stimulation (TENS) Units/Neuromuscular Stimulators	All units require approval
Transplants (except kidney and corneal)	All services
UPPP/Somnoplasty	All services
Wound Care Management	All services

Prescription Drugs Requiring Prior Approval

Medications without an NDC number (please provide name).

Drugs that have been on the market less than 12 months.

To get Prior Approval for prescription drugs, providers must submit the appropriate Approval Request Form for Prescription Drugs

The list of drugs that need Prior Approval changes from time to time. We will inform you of changes using newsletters and other mailings.

To check if a specific drug requires prior approval:

ask your doctor or
refer to the list of drugs that need prior approval by visting our website.
you may also call our customer service department at the number on the back of your I.D. card.

Prescription Drug Exclusions

We provide no prescription drug benefits for:

refills beyond one year from the original prescription date;
devices of any type other than prescription contraceptives, even though such devices may require a prescription order including, but not limited to: Durable Medical Equipment, prosthetic devices, appliances and supports (although benefits may be provided under other sections of your Contract);
any drug considered to be Investigational;
vitamins, except those which, by law, require a Prescription;
drugs that do not require a prescription, except insulin, even if your doctor prescribes or recommends them; and
nutritional formulae, except for up to $2,500 per year for "medical foods" prescribed for the Medically Necessary treatment of an inherited metabolic disease or those administered through a feeding tube.

Narcotics and antibiotics are limited to a 30-day supply.

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Quick Links Quick reference guide with CPT codes for Medical Services (including radiology) Requiring Prior Approval.

Quick reference guide with CPT codes for DME, Orthotics and Prosthetics.