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Prior Authorizations

Prior Authorization for Medical Services

This is the process of receiving written approval from Health Tradition for certain services before they are received. Some services require prior authorization even when provided by an in-network provider.

If you are a provider, please see our Provider Forms for additional authorization documents you may need to complete.

Medical Services

Services requiring prior authorization include, but are not limited to the following:

  • Behavioral Health Higher Levels of Care:
    • Inpatient services 
    • Intensive outpatient 
    • Partial hospitalizations
    • Residential services 
  • Dialysis (outpatient and home dialysis)
  • Durable Medical Equipment for the following items with a purchase OR rental price greater than $5,000
    • Electric Wheelchairs
    • Prosthetics
    • Zoll Vests
    • Compression Vests for Cystic Fibrosis
  • Genetic Testing
    • Exception: the following Genetic Testing Services DO NOT require Preauthorization:
      • CFTR/Cystic Fibrosis Transmembrane Conductance Regulator (81220)
      • Fetal chromosomal aneuploidy genomic sequence analysis panel (81420)
      • Fetal chromosomal microdeletion(s) genomic sequence analysis (81422)
      • Fetal aneuploidy DNA sequence analysis (81507)
      • Fetal congenital abnormalities (81511)
      • Spinal Muscular Atrophy (SMA) Carrier Screening (81329)
  • Hyperbaric Oxygen Therapy
  • Inpatient admissions (elective/planned, including observation stays that extend beyond 48 hours)
  • Intensity-Modulated Radiation Therapy (IMRT)
  • Invasive Back procedures (including injections, radio frequency ablation)
  • Nutritional support (enteral feedings)
  • Oncology Related Services:
    • All treatment regimens (including chemotherapy, radiation, services, procedures, etc.) being requested for a member with a cancer diagnosis requires prior authorization (Click here for Pre-Auth Form)
  • Orthognathic Surgery
  • Orthopedic Procedures, such as, but not limited to: 
    • Arthroscopic Procedures (knees, hips and shoulders)
    • Back Surgeries
    • Total Joint Replacements/Revisions/Repairs
  • Proton Beam Therapy
  • Reconstructive or plastic surgery such as, but not limited to:
    • Abdominoplasty
    • Blepharoplasty and ptosis repair
    • Brachioplasty
    • Breast augmentation, Lift, or Other Breast Reconstructive Surgery
    • Panniculectomy
    • Prophylactic Mastectomy
    • Septoplasty
    • Thighplasty
    • Treatment of varicose veins
  • Skilled Nursing Facilities
  • Skilled rehabilitation services
  • Sleep Studies in a Facility (In-home sleep studies do not require preauthorization.)
  • Specialty Drugs (See Prior Authorization for Drugs Listed Below)
  • TMJ/TMD Devices/Oral Appliances
  • Transplant evaluations, services, and procedures

Decisions on preauthorization requests submitted with all necessary clinical information will be made within 15 calendar days of receipt of the request. It is highly recommended you not schedule services prior to receiving an approved authorization.

Please note that the preauthorization of any procedure does not guarantee benefits or payment. Approval is based on medical appropriateness and necessity as defined in the patient’s benefit plan or certificate.

All benefits are subject to the term, conditions, and exclusions of the benefit plan or certificate.

 

 

Out-of-Area Services

Coverage outside of the service area for adult dependents who are full-time students

If an adult dependent full-time student plans to utilize non-emergency services from an out-of-network healthcare provider, it is the member’s responsibility to obtain prior authorization from Health Tradition.


Prior Authorization for Prescription Drugs

Certain medications require prior authorization. These are listed below and highlighted in the Health Tradition Formulary. You may also call Customer Service to ask if a medication requires prior authorization. Practitioners are responsible for submitting prior authorization requests.

If you are a provider, please use our Medication Preauthorization Form for the medications listed.

A-B-C

  • Abraxane
  • Actemra
  • Acthar Hp
  • Adagen
  • Adcetris
  • Adynovate
  • Afstyla
  • Aldurazyme
  • Alimta
  • Alprolix
  • Aralast Np
  • Aranesp
  • Aripiprazole Lauroxil
  • Artesunate
  • Ayvakit
  • Balversa
  • Beleodaq
  • Belrapzo
  • Benralizumab
  • Berinert
  • Besremi
  • Beuprenorphine Implant
  • Bivigam
  • Blenrep
  • Bortezomib
  • Botox
  • Botulinum
  • Brineura
  • C1 Esterase Inhibitor
  • Cablivi
  • Camptosar
  • Carimune
  • Cerezyme
  • Cerliponase Alfa
  • Cinqair
  • Cinryze
  • Coagadex
  • Copanlisib
  • Cosela
  • Crysvita
  • Cubicin
  • Cuvitru

D-E-F

  • Danyelza
  • Darzalex
  • Durvalumab
  • Dysport
  • Elaprase
  • Elelyso
  • Eligard
  • Elitek
  • Ellence
  • Eloctate
  • Emicizumab-Kxwh
  • Emtansine
  • Enfortumab Vedotin
  • Enhertu
  • Entyvio
  • Epoetin Alfa
  • Epoetin Beta
  • Epogen
  • Erbitux
  • Esperoct
  • Evenity
  • Evomela
  • Exkivity
  • Eylea
  • Fabrazyme
  • Factor Ix
  • Factor Viii
  • Fasenra
  • Faslodex
  • Firazyr
  • Flebogamma Dif
  • Flolan
  • Fotivda

G-H-I

  • Gamastan
  • Gammagard
  • Gammaked
  • Gammaplex
  • Gamunex
  • Gavreto
  • Glassia
  • Haegarda
  • Hemlibra
  • Herceptin
  • Herzuma
  • Hizentra
  • Humate-P
  • Hyqvia
  • Idamycin PFS
  • Idelvion
  • Ilaris
  • Imfinzi
  • Imlygic
  • Inflectra
  • Infugem
  • Inotuzumab Ozogamicin
  • Inrebic
  • Interferon Beta-1A
  • Interferon Beta-1B
  • Interferon, Alfa-2A
  • Interferon, Alfa-2B
  • Interferon, Alfacon-1
  • Interferon, Alfa-N3
  • Interferon, Gamma 1-B
  • Ipilimumab
  • Istodax
  • Ixempra Kit
  • Ixifi

J-K-L

  • Jelmyto
  • Jemperli
  • Jevtana
  • Jivi
  • Kadcyla
  • Kalbitor
  • Kanjinti
  • Kanuma
  • Keytruda
  • Khapzory
  • Kimmtrak
  • Kogenate Fs
  • Kovaltry
  • Kyprolis 
  • Lemtrada
  • Leukine
  • Leuprolide Acetate
  • Lorbrena
  • Lucentis
  • Lumakras
  • Lumizyme
  • Lupron
  • Lutetium

M-N-O

  • Makena
  • Margenza
  • Mepsevii
  • Methotrexate
  • Mircera
  • Monjuvi
  • Mozobil 
  • Mvasi
  • Mylotarg 
  • Myobloc
  • Myozyme
  • Naglazyme
  • Neupogen
  • Nivestym
  • Novoeight
  • Novoseven
  • Nplate
  • Nucala
  • Nuwiq
  • Nyvepria
  • Obizur
  • Ocrevus
  • Octagam
  • Ogivri
  • Onivyde
  • Onpattro
  • Ontruzant
  • Opdivo
  • Opdualag
  • Orencia Iv
  • Otrexup
  • Ozurdex

P-Q-R

  • Paclitaxel/Encequifar
  • Padcev
  • Parsabiv
  • Patisiran
  • Pemazyre
  • Pepaxto
  • Perjeta
  • Phesgo
  • Polivy
  • Portrazza 
  • Privigen
  • Procrit
  • Prolastin-C
  • Prolia
  • Qinlock
  • Rebinyn
  • Remicade
  • Remodulin
  • Renflexis
  • Retevmo
  • Retisert
  • Revcovi
  • Riabni
  • Rituxan
  • Rozlytrek
  • Ruconest
  • Ruxience
  • Rybrevant
  • Rylaze

S-T-U

  • Sandostatin
  • Sarclisa
  • Signifor Lar
  • Simponi Aria
  • Soliris
  • Somatuline Depot
  • Stelara
  • Supartz
  • Supprelin LA
  • Sylvant
  • Synagis
  • Takhzyro
  • Tecentriq
  • Tepmetko
  • Tivdak
  • Torisel
  • Totect
  • Trastuzumab-hyaluronidase
  • Trazimera
  • Tretten
  • Triluron
  • Trivisc
  • Trodelvy
  • Trogarzo
  • Truseltiq
  • Truxima
  • Tukysa
  • Turalio
  • Tivdak
  • Ukoniq
  • Ultomiris
  • Ustekinumab

V-W-X

  • Vectibix
  • Velcade
  • Veletri
  • Vimizim
  • Vpriv
  • Wilate
  • Xeomin
  • Xgeva
  • Xiaflex
  • Xolair
  • Xpovio
  • Xyntha

Y-Z

  • Yervoy
  • Yutiq
  • Zaltrap
  • Zemaira
  • Zepzelca
  • Zevalin Y-90 
  • Zinplava
  • Zirabev
  • Zokinvy
  • Zoladex