Prior Authorization (PA) Look-Up Tool
The Prior Authorization (PA) Look-Up Tool allows you to check if a specific procedure code or medication requires prior authorization. To check
if a procedure code requires prior authorization, use the “Procedure Codes” tab. To check if a Medicare Part B medication requires prior
authorization when it is delivered in the physician’s office, clinic, outpatient or home setting through home health or infusion companies, use the
“Medications” tab. When searching for medications, do not use J-codes.
The PA Look-Up Tool is not inclusive of all services that require prior authorization (e.g., non-Medicare covered items, HCPC codes and Rev codes are not
listed.) Services must be provided according to the Medicare Coverage Guidelines, established by the Center for Medicare & Medicaid Services (CMS),
and are subject to review. According to the guidelines, all medical care, services, supplies and equipment must be medically necessary. You
may review the Medicare Coverage Guidelines online at:
https://www.medicare.gov/coverage/your-medicare-coverage.html. Investigational and experimental procedures are not usually covered benefits.
Please consult the member’s Evidence of Coverage or contact the Health Plan for confirmation of coverage.
For a list of services requiring prior authorization, please refer to the Prior Authorization List (PAL)
Medications with Prior Authorization Requirements
Prior Authorization is required for the following Medicare Part B medications when delivered in the physician's office, clinic, outpatient or home setting through home health or infusion companies.
In addition, the following also require prior authorization:
- Any unclassified medications or biologics.
- Any Part D medication that is given in an outpatient setting (Infusion Center or MD office.) Please specify location (e.g. in MD Office/Infusion Center) on the authorization request.
- New FDA-approved injectables with Place of Service 11, 12, 19 or 22 (Part B drugs). These new injectable drugs will NOT appear immediately in the PA Look-Up Tool.
Do not use J-codes for medications.
Select a row from the list above to see details.
If you have any questions about the services and/or procedures that require prior authorization, please call us at the phone numbers listed below.