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Prior Authorization Updates

Date: 02/01/21

Arizona Complete Health-Complete Care Plan (AzCH-Complete Care Plan) requires prior authorization as a condition of payment for certain services. This notice contains information regarding new prior authorization requirements applied to the Medicaid line of business.

AzCH-Complete Care Plan is committed to delivering cost-effective quality care to our members. This effort requires us to make certain members receive medically necessary treatment according to current standards of practice.

Effective March 1, 2021, we are adding a prior authorization requirement for the services listed on the following pages to our existing prior authorization requirements.

We encourage you to use the Pre-Auth Check Tool available on our website before submitting a request to verify if prior authorization is needed. The web link to the Pre-Auth Check Tool is located here: https://www.azcompletehealth.com/providers/preauth-check.html.

ADDITIONAL INFORMATION

If you have questions regarding the information contained in this update, or need your assigned Provider Engagement Specialist contact information please email: AzchProviderEngagement@azcompletehealth.com.

  • 33285 INSERTION SUBQ CARDIAC RHYTHM MONITOR W/PRGRMG - Auth required
  • 76391 MAGNETIC RESONANCE ELASTOGRAPHY  - Auth required for under 21; all other ages not covered
  • 95115 PROF SERV ALLERG IMMUNOTX NOT INCL EXTRCT; 1 INJ - Auth required for under 21; all other ages not covered
  • 95144 PRO SERV SUPERVS/PROVS-IMMUNOTX; 1/MX ANTIG-1 VL - Auth required for under 21; all other ages not covered
  • 95145 PRO SERV SUPERVS/PROVIS-IMMUNOTX; 1 VENOM Auth required for under 21; all other ages not covered
  • 95146 PRO SERV-SUPERVS/PROVIS-IMMUNOTX; 2 VENOMS Auth required for under 21; all other ages not covered
  • 95147 PRO SERV-SUPERVS/PROVIS-IMMUNOTX; 3 VENOMS Auth required for under 21; all other ages not covered
  • 95148 PRO SERV-SUPERVS/PROVIS-IMMUNOTX; 4 VENOMS Auth required for under 21; all other ages not covered
  • 95149 PRO SERV-SUPERVS/PROVIS-IMMUNOTX; 5 VENOMS Auth required for under 21; all other ages not covered
  • 95170 PRO-IMMUNOTX; WHOLE BODY EXTRACT BITING INSECT Auth required for under 21; all other ages not covered
  • 95120 IMMUNOTHERAPY ONE INJECTION Auth required for under 21; all other ages not covered
  • 95125 IMMUNOTHERAPY 2/> INJECTIONS Auth required for under 21; all other ages not covered
  • 95130 IMMNTX 1 STING INSECT Auth required for under 21; all other ages not covered
  • 95131 IMMNTX 2 STING INSECTS Auth required for under 21; all other ages not covered
  • 95132 IMMNTX 3 STING INSECTS Auth required for under 21; all other ages not covered
  • 95133 IMMNTX 4 STING INSECTS Auth required for under 21; all other ages not covered
  • 95134 IMMNTX 5 STING INSECTS Auth required for under 21; all other ages not covered
  • J0287 INJ AMPHOTERICN B LIPID CMPLX 10 MG Auth required
  • J0289 INJ AMPHOTERICIN B LIPOSOME 10 MG Auth required
  • J0725 INJ CHORIONIC GONADOTROPIN PER 1000 USP UNITS Auth required
  • J0875 INJECTION DALBAVANCIN 5MG Auth required
  • J0878 INJECTION DAPTOMYCIN 1 MG Auth required
  • J0885 INJECTION EPOETIN ALFA FOR NON-ESRD USE 1000 UNITS Auth required
  • J1212 INJ DMSO DIMETHYL SULFOXIDE 50% 50 ML Auth required
  • J1570 INJ GANCICLOVIR SODIUM 500 MG Auth required
  • J1626 INJ GRANISETRON HYDROCHLORIDE 100 MCG Auth required
  • J2248 INJECTION, MICAFUNGIN SODIUM, 1 MG Auth required
  • J2358 OLANZAPINE LONG-ACTING INJ Auth required
  • J2545 PENTAMIDINE NON-COMP UNIT Auth required
  • J2786 INJECTION RESLIZUMAB 1MG Auth required
  • J2997 INJ ALTEPLASE RECOMBINANT 1 MG Auth required
  • J3101 TENECTEPLASE INJECTION Auth required
  • J3243 INJECTION, TIGECYCLINE, 1 MG Auth required
  • J3355 INJECTION UROFOLLITROPIN 75 IU Auth required
  • J7308 AMINOLEVULINIC ACID HCI FOR TICL ADMIN, 20%/1UNIT DOSAGE FORM (354MG) Auth required
  • J7320 GENVISC 850 INJ 1MG Auth required
  • J7342 CIPROFLOXACIN OTIC SUSP 6 MG Auth required
  • J7605 ARFORMOTEROL NON-COMP UNIT Auth required
  • J7626 BUDESONIDE, INHAL SOL, NON COMPOUND, ADMIN THRU DME, UNIT DOSE Auth required
  • J7799 NOC DRUGS, OTHER THAN INHALATION, ADMIN THRU DME Auth required
  • J7999 COMPOUNDED DRUG NOC Auth required
  • J8597 ANTIEMETIC DRUG ORAL NOT OTHERWISE SPECIFIED Auth required
  • J8670 ROLAPITANT ORAL 1MG Auth required
  • J9173 INJECTION DURVALUMAB 10 MG Auth required
  • J9205 INJ IRINOTECAN LIPOSOME 1 MG Auth required