Prior Authorization List

Prior authorization does not guarantee payment. Coverage of services is based on member eligibility and member’s benefits per the medical certificate of coverage at the time services are rendered. 
 
To request a specific medical policy guideline used in making prior authorization decisions, please contact Member and Provider Services at (608) 282-8900 or (800) 545-5015.

Services Requiring Prior Authorization (Effective as of July 1, 2017)

The following list of services require prior authorization from Plan before rendering services:

Acupuncture

Angioplasty (Outpatient)

Artificial Disc Replacement Surgery

Autism Intensive Therapy Services (Note: To obtain prior authorization and/or find a participating provider, contact UW Behavioral Health at (608) 417-4709 or (800) 683-2300)

Bariatric Outpatient Surgery

Bone Anchored Hearing Aid (BAHA)

Category III CPT Codes

Cosmetic Procedures (Potential) Including, but not limited to:

  • Benign skin lesions (including the removal of sebaceous cysts, hemangioma, lipoma and laser treatment for psoriasis)
  • Blepharoplasty
  • Botox Injections
  • Canthoplasty
  • Male Gynecomastia
  • Microtia
  • Reduction Mammoplasty
  • Rhinoplasty
  • Skin Tag Removal (benefit ETF members only)
  • Varicosity Procedures

Cranial Orthotic Devices (for the correction of Craniosyntosis after surgical correction)

Deep Brain Stimulation (DBS)

Durable Medical Equipment (DME)*

  • All DME purchases over $750
  • All DME rentals over $750/month
  • All CPAP machine purchases
  • Continuous glucose monitoring (CGM) transmitter

Electroconvulsive Therapy 

Gastric Stimulators

Genetic Testing & Molecular Pathology

Home Care Services, Supplies & Therapies

Infusion Medications (See Pharmacy Medication Pre-authorization List

Inpatient Services, including but not limited to:

  • Acute Care Facility
  • Hospice Facility
  • Long Term Acute Care Facility
  • Rehabilitation Facility
  • Skilled Nursing Facility (including therapy)
  • Subacute Facility
  • Maternity services not related to delivery

Intrathecal Pump Implantation 

Intratympanic Steroid Injection

Lumbar Discography

MRI, Lumbar Spine

Non-emergent Patient Transportation (See provider forms)

Non-participating Providers: All Services

Oral/Orthognathic Surgery

Orthopedic/Neurosurgery Referrals (ETF Members Only)

Prophylactic Ovary/Breast Removal

Spinal Cord Stimulators

Prosthetics, Limb: All Purchases

Stem Cell Storage (Non-Transplant)

Transplant Evaluations & Services

 Note: For Covered Persons with a Medicare Supplement Policy, prior authorization is only required for nursing home stays.


*Durable Medical Equipment (DME)

Definition: Plan defines Durable Medical Equipment (DME) as an item which can withstand repeated use and which, as determined by Plan, meets all of the following:

  • A) Primarily used to serve a medical purpose with respect to an illness or injury;
  • B) Generally not useful to a person in the absence of an illness or injury;
  • C) Appropriate for use in the member's home, but may not be limited to home use; and
  • D) Prescribed by a physician.

Non-covered DME items require prior authorization if the cost is $750 or more. However, that does not guarantee payment by Plan. Some DME items are considered over-the-counter items or are otherwise benefit exclusions. Other DME items have quantity limitations and are not payable by Plan once the Covered Person has received the maximum number of items for that benefit year.

In addition, all limb prosthetics require prior authorization regardless of the cost. Medical necessity guidelines will apply for any DME or prosthetic purchased.

All DME purchases and rentals are subject to Covered Person coinsurance amounts and deductibles.

Prescription Drugs and Pharmacy

Prescription drug prior authorization requirements are in the plan formulary, and the member, his or her designee, or the prescriber are responsible for obtaining the prior authorization.

General information:

  • All non-formulary and prescription drugs requiring prior authorization must be deemed medically necessary by Physicians Plus for coverage.
  • Prior authorization requests based solely upon convenience or personal preference will not be approved.
  • All specialty drugs and select medications on the formulary require prior authorization.