ALL PROCEDURES/TESTS REQUIRE PRIOR AUTHORIZATION EXCEPT
OFFICE VISITS, AND ROUTINE DIAGNOSTIC OUTPATIENT LAB AND
RADIOLOGY SERVICES
SERVICES MUST BE MEDICALLY NECESSARY
ONLY OUTPATIENT SERVICES COVERED – NO INPATIENT SERVICES
EMERGENCY DEPT SERVICES NOT COVERED
*Chemotherapy services - Not Covered
SERVICES THAT REQUIRE PRIOR AUTHORIZATION (PA) FOR PAYMENT
SERVICES
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ADDITIONAL INFORMATION
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Infusion Services*
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Limited benefit
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Injection Medications*
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Limited benefit
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Ophthalmologic exams and testing
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Medically necessary – no vision services
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Physical Therapy
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12 visits per year, add visits with PA
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Outpatient Surgeries
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Radiation Therapy
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Genetic testing
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Reconstruction Surgery
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Skin Procedures
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Sleep Study
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Vein Treatments & Surgery
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Any service that could be considered cosmetic or not medically necessary
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Unclassified procedure codes
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Behavioral Health Continued Coverage
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When individual has continued need after exhausting the 15 visits of the limited coverage benefits and attempts have been made to refer the individual to other public resources
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