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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:

  • Advanced Imaging

    • CT of the Neck or Spine

    • MRI of the Neck or Spine

    • PET Scans

  • Arthroscopic Procedures (Knees, Hips and Shoulders)

  • Autologous Chondrocyte Implantations

  • Behavioral Health Higher Level of Care:

    • Inpatient services 

    • Residential services 

    • Partial hospitalizations 

    • Intensive outpatient 

    • Behavioral health day treatment

  • BAHA (bone anchored hearing aids)

  • Cochlear Implants

  • Continuous Glucose Monitoring Systems

  • Continuous Passive Motion Device (knee use only)

  • Dental/Oral Surgery

  • DME and Orthotic Devices with a purchase OR rental price greater than $1,000

  • Dialysis (outpatient and home dialysis)

  • Experimental OR Investigative Services

  • Genetic Testing

    • Exception: the following Genetic Testing Services do not require Preauthorization: 

      • 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)

  • Helmet for Positional Plagiocephaly

  • Home Health Services including Wound Care

  • Home INR Demonstration and Monitoring

  • Home Infusion

  • Intensity-Modulated Radiation Therapy (IMRT)

  • Insulin Pumps

  • Invasive back procedures (injections, surgery, radio frequency ablation)

  • Inpatient admissions (including observation stays that extend beyond 48 hours)

  • Negative Pressure Wound Therapy

  • Neurostimulators

  • Non-emergency Ambulance Transportation

  • Noninvasive Airway Assist Devices

  • Nutritional support and counseling

  • Oncology Related Services:

    • *All treatment regimens (including chemotherapy, radiation, services, procedures, etc.) being requested for a member with a cancer diagnosis requires pre-approval

  • Orthognathic Surgery

  • Outpatient Hysterectomies 

  • Psychological and Neuropsychological Testing

  • 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 M

    • Astectomy

    • Thighplasty

  • Pneumatic Compression Devices and Appliances

  • Proton Beam Therapy 

  • Skilled Nursing Facilities

  • Skilled rehabilitation services

  • Sleep Studies in a Facility (In-home sleep does not require preauthorization.)

  • TMJ treatments

  • Transplant evaluations, services and procedures

  • Treatment of varicose veins

  • Ultrasound Elastography

  • Upper Airway Stimulation (UAS) Therapy

All services/procedures/surgeries for a member with a cancer diagnosis must be reviewed and approved by INTERLINK® CancerCARE.

The Certificate of Coverage fully defines services requiring referrals or prior authorizations to obtain coverage. Payment for those services will not be made unless prior authorization is obtained. Prior authorization alone does not guarantee payment of benefits.

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
  • Fulphila

G-H-I

  • Gamastan
  • Gammagard
  • Gammaked
  • Gammaplex
  • Gamunex
  • Gavreto
  • Glassia
  • Granix
  • 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
  • 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
  • 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
  • Udenyca
  • Ukoniq
  • Ultomiris
  • Ustekinumab

V-W-X

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

Y-Z

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