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Prior Authorization is required for:

  • All inpatient stays for medical and/or psych and substance abuse.
  • All outpatient surgeries not done in a doctor’s office.
  • All services listed below regardless of place of service.
    1. 23 – hour Observation stays
    2. Deviated Septum/Nasal Surgery
    3. EBCT (Electron Beam Tomography)
    4. Endoscopic Procedures
    5. MRI/CT/Pet Scan- excludes bone density studies
    6. Physical/Occupational/Speech Therapy - beyond 12 visits
    7. Any Drug above $1500 a dose or the amount listed in the plan document
    8. Biologic Drugs
    9. Chemotherapeutic Drugs
    10. Dialysis
    11. DME (rental or purchase) over $1000 or the amount listed in the plan document
    12. Epidural/ facet and trigger point injections
    13. Extended Nursing Facility
    14. Gastric Bypass / Panniculectomy /Abdominoplasty
    15. Home Health Care
    16. Hospice Care
    17. Infusions (Infusion Therapy) of any type over $1500 or the amount listed in the plan document
    18. Long Term Acute Care (LTAC)
    19. Behavioral Health: Intensive Out Patient Program, Residential Treatment Centers, Partial Hospitalization Program
    20. Radiation Treatments
    21. Skilled Nursing Facility (SNF)
    22. Inpatient Rehabilitation
    23. Cosmetic Surgery Potentials:
    24. Mammoplasty
    25. Blepharoplasty
    26. Varicose Veins stripping and ligation
    27. On-going Wound Care
    28. Other

Please note, all services are subject to medical necessity.

Click to submit a Prior Authorization Form