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Prior Authorization Lists

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Medicare Advantage

The services listed here require prior authorization for any members enrolled in the following Horizon Medicare Advantage/Medicare Advantage Prescription Drug (MA/MAPD) plans:

  • Horizon Medicare Blue Value (HMO)
  • Horizon Medicare Blue Value w/Rx Standard (HMO)
  • Horizon Medicare Blue Value w/Rx Enhanced (HMO)
  • Horizon Medicare Blue Access (HMO-POS)
  • Horizon Medicare Blue Access w/Rx Standard (HMO-POS)
  • Horizon Medicare Blue Access w/Rx Enhanced (HMO-POS)
  • Horizon Medicare Blue TotalCare (HMO SNP) NEW for 2012
  • Horizon Medicare Blue Access Group (HMO-POS)

SERVICES REQUIRING PRIOR AUTHORIZATION FOR ALL MA/MAPD PLANS

Please note that the following services require prior authorization for members enrolled in any of the above mentioned plans. 

Following this list is another list of services that require prior authorization ONLY FOR members enrolled in the Horizon Medicare Blue TotalCare (HMO SNP) plan.

  • All Inpatient Admissions (excluding maternity admissions)
  • All elective acute care admissions (excluding maternity admissions) including:
    • Elective Surgical admissions
    • Elective Medical admissions
    • All rehabilitation facility admissions (e.g., Acute Rehab, Skilled Nursing Facility (SNF) and Sub-Acute admissions)
    • Mental health and substance abuse admissions (Prior authorization is performed by Magellan Behavioral Health)
  • Ambulance transportation (non-emergent only) - Ground or Air
  • Bariatric Procedures (for example: Gastric Bypass)
  • Breast Reconstruction
  • Cardiac Radiology Services (Non emergent only)
    (Prior authorization performed by CareCore National (CCN)
  • Diagnostic Cardiac Catheterization / Echo Stress (Non-emergent only)
    (Prior authorization performed by CareCore National (CCN)
  • Cosmetic Procedures - any potentially cosmetic procedure including cosmetic dermatology services; Examples:
    • Breast Reconstruction / Reduction Mammoplasty
    • Excision of Excessive Skin - Lipectomy
    • Gynecomastia - surgical treatment
    • Orthognathic Surgery
    • Rhinoplasty/Rhytidectomy/Septoplasty/Sinus Surgery
    • Sclerotherapy or Surgery for Varicose Veins
    • Cosmetic Eyelid surgery (e.g., Blepharoplasty/Canthoplasty)
  • Durable Medical Equipment (DME) and Prosthetics - Certain DME/Prosthetic items costing over $500 and most DME rentals.  (Prior Authorization is NOT required for Home Oxygen)
  • Home Health Care Services (All skilled services provided in the home)
  • Home Infusion Services
  • Orthognathic Jaw Surgery
  • Out-of-network requests for consideration of In-Network level of benefit when a network deficiency exists
  • Pain Management Injections (Prior authorization performed by CareCore National (CCN)
  • Radiology services (Prior authorization performed by CareCore National (CCN)
    • CT/CTA Scans
    • MRI/MRA
    • Nuclear Medicine/Nuclear Cardiology
    • PET and PET/CT Scans
  • Sinus and Nasal Surgery
  • Surgery for Sleep Apnea (e.g., Uvelopalatopharyngoplasty [UPPP]/uvelopalatoplasty [UPP])
  • Specialty Pharmaceuticals/Drugs (e.g., Botox, IVIG, Flolan and derivates; Xolair)
  • Temporomandibular Joint Surgery
  • Transplant Services (excluding Corneal Transplants)
  • Occupational Therapy
  • Physical Therapy
  • Varicose Vein Surgery (Sclerotherapy)

 ADDITIONAL SERVICES REQUIRING PRIOR AUTHORIZATION ONLY FOR MEMBERS ENROLLED IN Horizon Medicare Blue TotalCare (HMO SNP) plans

Please note that, in addition to the above-listed services, members enrolled in the Horizon Medicare Blue TotalCare (HMO SNP) plan must also obtain Prior Authorization for the services listed below.

  • Chiropractic Services
  • Dental Services (as indicated below):
    • Crowns
    • Dentures and periodontics
    • Orthodontics for members under the 18 years of age where medical necessity is established and/or to correct a facial abnormality
    • Dentures
    • Bridgework
    • Oral Surgery
  • Hospice services (palliative and curative care) for members under age 21 years
  • Hysterectomy
  • Medical Day Care health services (Adult and Pediatric)
  • Nutritional supplements and foods associated with genetic disorders or inborn errors of metabolism and treatment of weight loss due a medical condition
  • Organ Transplants
  • Personal Care Assistant Services (PCA)
  • Private duty nursing services provided to all eligible members under age 21 years
  • Speech Therapy

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