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Provider resources for
pre-authorization and more

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Pre-authorization
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For Searchable Formulary And Rx Pre-authorization List

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Find Additional Helpful Resources Go to the Department of Insurance

Service Requiring Pre-Authorization

  • Services being performed in the Emergency Department do NOT require prior authorization.
  • Services being performed or ordered by a non-participating provider REQUIRES prior authorization.
  • Admission to an inpatient facility from a participating and non-participating providers REQUIRES prior authorization, including transfers from one facility to another, intensive (IOP), partial hospitalization (PHP), and residential treatment center (RTC).
  • See below for additional service requiring authorization.

This list may not be all-inclusive. Services must be provided by participating providers.

Please call if you are uncertain whether a referral is necessary, or a provider is participating.

Services Requiring Authorization

Authorization Service CategoryComments

Admissions

ALL planned or scheduled inpatient admissions, includes medical, behavioral health, surgical admissions, hospice, including transfers from one facility to another

Acute Rehabilitation

ALL Inpatient Rehabilitation, Long Term Acute Care Hospital, Skilled Nursing Facilities

Ambulance or Air/Water Transport

Ambulance or Air/Water Ambulance (Non-Emergent) transport or transfer generally not covered

Any Experimental/ Investigational Services

Experimental/ Investigational medical and surgical procedures, equipment, and medications

Behavioral Health Services

Behavioral Health Services

  • Applied Behavioral Analysis (ABA)
  • Electroconvulsive Therapy (ECT) Applied
  • Neuropsychological and Psychological Testing
  • Intensive outpatient program (IOP)
  • Partial Hospitalization (PHP)
  • Residential treatment center (RTC)

Clinical trials

All clinical trials including cancer and clinical innovation

Dental

All dental related services. Generally not covered.

Dialysis

All services

Durable Medical Equipment & Prosthetics

  • All DME Rental
  • Some items require authorization.

Hematology and Oncology

Cancer treatment including chemotherapy, radiation, and surgery; Submit treatment plan as soon as known to facilitate rapid approval of necessary services

Imaging Advanced & Diagnostic Procedures

Arteriogram, Angiograms, CT/CTA scans, MRIs/MRAs, PET scans (exception breast MRI doesn’t require preauthorization)

Gene Therapy and Molecular Diagnostic Testing

  • Cancer treatment including chemotherapy, radiation, and surgery; Submit treatment plan as soon as known to facilitate rapid approval of necessary services
  • All gene therapy
  • In network lab: Quest Diagnostics and Bioreference (see website for up to date in network provider information)

Home Services*
(plan specific benefit)

In network home health: see provider
directory for up to date information

Arteriogram, Angiograms, CT/CTA scans, MRIs/MRAs, PET scans (exception breast MRI doesn’t require preauthorization)

The following surgeries when
performed in an Inpatient,
Outpatient, or office location.

  • Back injections (ESI, RFA, MBB, Facet, ect.)
  • Bariatric Surgery
  • Blepharoplasty - Brow Lift
  • Breast Procedures
  • All Cosmetic surgery: not covered when performed to improve appearance
  • All infusions
  • Hyperbaric oxygen therapy
  • Photodynamic therapy
  • Spine Procedures
  • Neurostimulators
  • Ophthalmologic procedures
  • Some Joint Surgeries (Knee, Hip, Shoulder)
  • Some Ear Nose and Throat, Oral-Maxo facial, Integumentary, Gastrointestinal, Female and Male Genital, Reproductive, Ophthalmologic, Orthopedic, Neurological, Fertility
  • CAR-T Cell therapy procedures

Miscellaneous, Unlisted Codes
and T Codes

Miscellaneous, unlisted codes and T codes are not covered, unless otherwise stated in the provider’s contract.

Physician Administered Drugs:
Some Specialty Rx/Infusions

Most drugs require prior authorization eg. biologicals, supportive care drugs, immunoglobulins, viscosupplementation, etc. Please see the list below for common examples, call Evry Health to confirm if physician administered drug is not listed below.

Plan Specific Provisions:
Check member benefit/
eligibility for eligibility.

  • Child Developmental Delays for rehabilitative and habilitative services
  • Home Health which includes a limit to 60 visits per calendar year combined modalities
  • Treatment of Mental or Emotional Illness or Disorder when confined to a hospital or Psychiatric Day Treatment Facility
  • In-Vitro Fertilization/Fertility
  • Speech and Hearing Assistance
  • Bariatric Surgery
  • Transgender Services

Transplants and Transplant
related services

All Transplants

  • Includes Transplant Evaluations, Pre- & Post- Operative Services/Care

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