Services that need prior authorization

Some medical services or provider visits require prior authorization. This helps us manage your care and ensure you receive the care you need when it’s medically necessary.

Here are the most common services that require prior authorization. This list is not comprehensive. For specific benefit information and documented confirmation of services requiring prior authorization, contact Member Services at 800-279-1301.

A little girl and her mother meeting with a pediatrician

  • Air ambulance, non-emergent
  • Bariatric surgery
  • Durable medical equipment (DME): as stated in our medical policies
  • Elective hospital inpatient admissions and services
  • Gender affirmation surgery
  • In-lab sleep studies for adults
  • Inpatient behavioral health and addiction services
  • Inpatient rehabilitative confinement
  • Certain medical injectables
  • Medical supplies (e.g., outpatient tube feeding formula)
  • New technologies not commonly accepted as standard of care
  • Orthognathic surgery - approved orthognathic surgical procedures
  • Select pain management services
  • Certain outpatient behavioral health and addiction services (e.g., partial hospitalization, residential treatment, or day treatment)
  • Certain outpatient hospital or ambulatory surgical - Surgical care at an ambulatory surgical center or a provider’s office
  • Certain outpatient radiology services (e.g., MRI, CT, PET scan)
  • Select diagnostic testing
  • Select pain management services
  • Skilled nursing facility/swing bed
  • Transplant services – (except cornea)