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.

Acne Treatment

Actemra (tocilizumab)– Medical Benefit Drug

Acupuncture

Ambulatory Blood Pressure Monitoring (ABPM)

Arcalyst (rilonacept)– Medical Benefit Drug

Artificial Disc Replacement Surgery

Autism Intensive Therapy Services

Bariatric Surgery

Benign Skin Lesions

Benlysta (belimumab)– Medical Benefit Drug

BAHA - Bone Anchored Hearing Aid

Boniva (ibandronate intravenous) - Medical Benefit Drug

Botox Injections

Category III CPT Codes

Clinical Trial

CT (Virtual) Colonoscopy

Deep Brain Stimulation

Dental Services Coverage Under Medical Plans

Dental Services in the Emergency Room

Durable Medical Equipment (DME)

Electroconvulsive therapy 

Fecal Bacteriotherapy

Female Reduction Mammaplasty

Functional Electrical Stimulation

Genetic and Genomic Outpatient Testing 

Gynecomastia Surgery

Hereditary Angioedema - Medical Benefit Drug

High Frequency Chest Wall Compression Systems

Home care services, supplies

Hospice, Inpatient  

Ilaris (canakinumab)– Medical Benefit Drug

Immunoglobulin (IV&SC) - Medical Benefit Drug

 

Insulin Pumps / Continuous Glucose Monitors

Intrathecal Pump Implantation 

Intratympanic Steroid Therapy

Iron Infusion

Laser Treatment for Psoriasis 

Lumbar Discography

Orencia (abatacept) - Medical Benefit Drug

Oral/Orthognathic Surgery

Orthopedic and Neurosurgery Referrals for ETF Members with Low Back Pain

Percutaneous Left Atrial Appendage Closure

Phototherapy (SAD Lights) for Psychiatric Disorders

Preimplantation Genetic Diagnosis

Prolia (denosumab)– Medical Benefit Drug

Prophylactic Mastectomy and Oophorectomy

Prosthetic Limb Devices

Prosthetics, Limb: All Devices

Reclast (zoledronic acid intravenous) - Medical Benefit Drug

Radiofrequency Thermal Ablation for Barrett's Esophagus

Recurrent Pregnancy Loss

Remicade (infliximab) - Medical Benefit Drug

Rituxan (rituximab) - Medical Benefit Drug

Skin Tag Removal (ETF Members Only)

Spinal Cord Simulators

Stereotactic Radiosurgery

Stem Cell Storage (Non-transplant)

Synagis (palivizumab) - Medical Benefit Drug

Transplant Evaluations & Services

Tysabri (natalizumab) - Medical Benefit Drug

Vagus Nerve Simulation

Varicose Vein Procedure

Xolair (omalizumab) - Medical Benefit Drug