Prior Authorization Requirement Update

Date: 01/29/21

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.

Procedure Code	Procedure Description	Requirement
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

Procedure Code	Procedure Description	Requirement
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