Health Care Practitioners
Prior Authorization List

Monthly updates will be added to the Prior Authorization list. Providers are reminded to review the Prior Authorization list on a regular basis for any updates or changes which may be added. Please contact Customer Service with specific code information to determine if an item or service requires prior authorization.

Durable Medical Equipment

  • Airway Clearance Devices
  • Bone Growth Stimulators
  • Braces / splints over $500
  • Cardiac defibrillator (external only)
  • Continuous glucose monitors
  • Continuous passive motion machines
  • CPAP, BiPAP (rental and purchase)
  • Custom shoes and custom-molded foot orthotics (limited benefit) includes orthopedic shoes
  • Cystic Fibrosis vests
  • Dynamic Orthotic Cranioplasty (DOC) bands
  • Electric Tumor Treatment Fields (TTF) Device (Optune®) ​
  • Home monitoring devices
  • Home Phototherapy (UVB) Light Devices for Treatment of Psoriasis​
  • Hospital beds and related supplies
  • Insulin pumps
  • Life sustaining nutritional therapies
  • Mechanical stretching devices
  • Patient​ lift ​equipment
  • Prosthetics, including upper extremity, lower extremity, eye, face, etc.
  • Spinal Traction Devices
  • Standing Frame / Stander
  • TENS and other e-Stim devices
  • Walk-aid devices (electronic or e-Stim)
  • Wheelchairs and motorized scooters

Wound Therapy (Advanced), including Negative Pressure (Vac) Therapy, Noncontact Normothermic Wound Therapy (NNWT) and Bioengineered Skin Substitutes


Experimental and Investigational Treatments


Genetic Testing including Pharmacogenetics Testing


Home Health Care including home infusion services and other in-home therapy services


Hospice Care


Inpatient Admissions

Note: Urgent / emergent hospital admissions require notification at the time of admission. Elective hospital admissions require prior authorization before admission and notification when admitted.

  • Hospitals, Acute Inpatient Care
  • Inpatient Rehabilitation Facilities
  • Long Term Acute Care (LTACH)
  • Psychiatric ​Admissions
  • Skilled ​Nursing ​Facility / ​Swing ​Bed

Other Services

  • CAR T Cell therapy
  • Day treatment
  • Extended Cardiac Rhythm Monitoring (External and Implanted Cardiac Monitors/Loop Records)
  • Fecal Bacteriotherapy ​
  • Outpatient High Tech Radiology Services (ETF Only)*
    • Cardiac Nuclear Stress Tests
    • CT and CTA
    • MRI and MRA
    • PET Scan
  • Intensive Outpatient Program (IOP)
  • Non-emergent Ambulance Services
  • Partial Hospital Program (PHP)
  • Platelet-Rich Plasma (PRP) Injections​
  • Residential treatment
  • Steroid Releasing Sinus Implants
  • TheraSphere / Sir-spheres Treatment ​
  • Transcranial Magnetic Stimulation (TMS)
  • Vagus Nerve Stimulation
  • Wireless / remote heart failure monitoring devices (CardioMems™)

*UW Health and Meriter UnityPointClinics are exempt from prior authorization for High Tech Radiology Services


Out-of-Network services or supplies


Medications

Prior authorization is required for clinic-administered medications listed below. Practitioners must submit a prior authorization request via MyPlanTools or fax a Medication Prior Request Form to Quartz at (888) 450-4711.

  • Abatacept IV (Orencia)
  • Abobotulinum toxin A (Dysport)
  • Alemtuzumab (Lemtrada)
  • Alglucosidase alfa (Lumizyme, Myozyme)
  • Alpha-1 proteinase inhibitors (Glassia, Aralast NP, Prolastin C, Zemaira)
  • Anti-Inhibitor (Feiba NF)
  • Atezolizumab(Tecentriq)​
  • Avelumab (Bavencio)​
  • Belimumab (Benlysta) infusion​
  • Benralizumab (Fasenra) ​
  • Buprenorphine (Probuphine) implant
  • C1 esterase inhibitor (Berinert)
  • C1 esterase inhibitor (Cinryze)
  • C1 esterase inhibitor (Haegarda)
  • C1 esterase inhibitor (Ruconest)
  • Cankinumab (Ilaris)
  • Carfilzomib (Kyprolis)
  • Cerliponase alfa (Brineura) ​not covered - experimental
  • Corticotropin (Acthar H.P.)
  • Daratumumab (Darzalex)
  • Denosumab (Prolia, Xgeva)
  • Dupilumab (Dupixent) ​
  • Durvalumab (Imfinzi)
  • Ecallantide (Kalbitor)​
  • Eculizumab (Soliris)
  • Edaravone (Radicava)​
  • Elotuzumab (Empliciti)
  • Eteplirsen (Exondys) not covered – experimental
  • Factor IX (Alphanine SD)
  • Factor IX (Aprolix)
  • Factor IX (Bebulin VH)
  • Factor IX (Benefix RT)
  • Factor IX (Idelvion)
  • Factor IX (Ixinity)
  • Factor IX (Mononine)
  • Factor IX (Profilnine)
  • Factor IX (Rixubis)
  • Factor VII (Humate-P)
  • Factor VII (NovoSeven RT)
  • Factor VIII (Advate)
  • Factor VIII (Adynovate)
  • Factor VIII (Afstyla)
  • Factor VIII (Alphanate)
  • Factor VIII (Eloctate)
  • Factor VIII (Helixate FS)
  • Factor VIII (Hemofil)
  • Factor VIII (Koate)
  • Factor VIII (Kogenate FS)
  • Factor VIII (Kovaltry)
  • Factor VIII (Monoclate-P)
  • Factor VIII (Novoeight)
  • Factor VIII (Nuwiq)
  • Factor VIII (Recombinate)
  • Factor VIII (Wilate )
  • Factor VIII (Xyntha)
  • Factor XIII (Corifact)
  • Golimumab IV (Simponi)
  • GNRH agonist ( leuprolide, Lupron, Vantas, Supprelin LA) for use in gender dysphoria
  • HCG Injections (Novarel, Pregnyl)
  • HPV vaccine for ages outside of 9-26 years (Gardasil)
  • Hydroxyprogesterone caproate (Makena)
  • Icatibant (Firazyr)
  • Incobotulinum (Xeomin)
  • Infliximab (Remicade, Renflexis, Inflectra)
  • Letermovir (Prevymis)​
  • Lutetium Lu 177 dotatate (Lutathera) ​
  • Mepolizumab (Nucala)
  • Naltrexone Extended Release Injection (Vivitrol)
  • Natalizumab (Tysabri)
  • Nivolumab (Opdivo))
  • Nusinersen (Spinraza)
  • Ocrelizumab (Ocrevus)
  • Omalizumab (Xolair)
  • Onabotulinum toxin A (Botox)
  • Palivizumab (Synagis)
  • Pegfilgrastim (Neulasta)
  • Pembrolizumab (Keytruda)
  • Renflexis (Infliximab-Abda)​
  • Reslizumab (Cinqair)
  • Rilonacept (Arcalyst)
  • Rimabotulinum toxin B (Myobloc)
  • Romiplostim (Nplate)
  • Sebelipase alfa (Kanuma)
  • Testosterone Cypionate (Depo-Testosterone)
  • Testosterone Enanthate (Testosterone Enanthate)
  • Testosterone Implant (Testopel)
  • Testosterone Undecanoate (Aveed)
  • Tocilizumab (Actemra)
  • Ustekinumab (Stelara)
  • Vedolizumab (Entyvio)
  • Voretigene neparvovec-RZYL (Luxturna)​
  • Xofigo (Radium 223 Dichloride)
  • Zinplava (Bezlotoxumab)
  • Zoster vaccine for age <50 years (Shingrix)​​
  • Zoster vaccine for age <60 years (Zostavax)
  • Medications billed under miscellaneous codes (examples; J3490, J3590) with amount billed > $2500

Surgical Procedures

The following procedures must be prior authorized before they are scheduled.


  • Abortions including multi-fetal reductions
  • Bariatric Surgery
  • Blepharoplasty
  • Bone Anchored Hearing Aids (BAHA)
  • Breast Surgery
  • Brow lifts
  • Cochlear Implants
  • Corneal Cross-linking
  • Endoscopic procedures for Reflux Management ​
  • Implantable Nerve Stimulators
  • Laser re-surfacing for non-cosmetic procedures (cosmetic procedures are excluded)
  • Laser treatment of actinic keratosis or other benign skin lesions
  • Left Ventricular Assist Devices (LVAD) for Treatment of Heart Failure ​
  • Orthopedic Procedures Including Artificial Cervical and Lumbar Disc Surgery, OATS Procedures and Hip Resurfacing
  • POEM Procedure
  • Panniculectomy
  • Prosthetic Urethral Lift (Urolift®) ​
  • Removal of port wine stains and hemangiomas
  • Rhinoplasty and septorhinoplasty
  • Robotic Assisted Procedures
  • Scar revision and repair
  • Surgical Treatment of Pectus Excavatum and Carinatum Syndrome
  • Temporomandibular Joint Disease surgical treatment
  • Transgender Surgery
  • Transplants including donor and other related charges (excludes corneal except for artificial corneal transplants)
  • Transcatheter Closure of  Septal Defect
  • Surgical Treatment of Obstructive Sleep Apnea
  • Varicose Vein or Spider Vein Procedures including Sclerotherapy, Radiofrequency Ablation, Vein Stripping and Ligatio

Therapies

  • Biofeedback (only covered for spastic torticollis, headache or pediatric urinary incontinence)
  • ​Extracorporeal Shockwave Therapy
  • Hyperbaric Oxygen Therapy
  • Prolotherapy
If you have any questions about the prior authorization list or want to know if a service or supply requires prior authorization, please contact Customer Service through the message center within MyPlanTools for providers or MyChart for members or call (800) 362-3310.