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Prior Authorizations

Prior Authorization means your doctor has requested permission for you to get a special service, medication or referral. We must approve these requests before the delivery of services. If you or your provider would like a referral to a service that is not a covered benefit, please call Member Services at 1-888-788-4408, TTY/TDD 711 so we can discuss other options available to you.

Some medical and behavioral health services may need Prior Authorization. For example, non‑emergency hospital admissions or others such as:

  • Behavioral Health Inpatient Facility
  • Behavioral Health Residential Facility
  • Home Care Training to Home Care Clients (HCTC)
  • Psychological and Neuropsychological Testing
  • Electroconvulsive Therapy (ECT)
  • Non‑emergency out of network services/treatments
  • Some medications, check the list of approved medications (formulary)
  • MRI, MRA, PET scans
  • Special lab work, genetics
  • Surgeries, pre-scheduled
  • Dialysis
  • Some Outpatient procedures and surgeries
  • Transplant
  • Bio pharmacy (Buy and Bill)

If they do, your provider will arrange for authorization for these services. We must review these authorization requests before you can get the service.

Criteria that decisions are based on are available upon request.