Provider resources forpre-authorization and more

Download the evry health
pre-authorization request form.

Upload the evry health
pre-authorization request form.

Visit Magellanrx for
For pharmacy pre-authorization.

Search our directory for in-network hospital
labs, asc, and home health partners.

Find additional helpful resources
go to the department of insurance.

Services Requiring Pre-Authorization

Category Service Comments


Limted to 5 per calendar year.

See medical policy at


All planned or scheduled inpatient medical, behavioral health and surgical admissions including acute, rehab, and skilled nursing facility.

Including transfers from one facility to another, intensive outpatient program (IOP), partial hospitalization (PHP), and residential treatment center (RTC).

Exceptions: For maternity admission for vaginal delivery or C-section where notification is required within 24 hours or one business day of the admission.

Ambulance or Air Transport

Non-emergent transport or transfer

Generally not covered.

Bariatric Surgery

All services require prior authorization

Generally not covered. Plan specific benefit for initial and/or revision.

Breast reconstruction

Post - mastectomy for breast cancer and revisions

Breast reductions also covered with medical necessity authorization.

Clinical Trials

All clinical trials including cancer and clinical innovation


Limited to 5 per calendar year.

See medical policy at


All dental related services

Generally not covered.

DME/Devices Replacement of devices every 36 months

Durable medical equipment over $1000. Including orthotics and prosthetics

Evry's in network provider for DME is Apria

Cochlear implants

Hearing Aids