Prior Authorization List - PDF

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					                                          PRIOR AUTHORIZATION LIST


Prior Authorization List
Effective July 14, 2008
APPLICABLE GROUPS: ALL MEDICARE AND COMMERCIAL FULLY INSURED GROUPS.

For prior authorization lists for Self-funded groups, members should contact SummaCare Customer Service and providers
should log onto Plan Central on www.summacare.com or contact SummaCare Provider Services. Network providers must obtain
authorization 48 hours prior to rendering service for the services listed below. For PPO members, when outside the coverage
area, it is the member’s responsibility to verify that the necessary prior authorization has been obtained. Coverage decisions are
based on plan benefits and appropriateness of care and service. Prior authorization requests may be made by calling the Benefits
Determination Unit at 330-996-8710 or 888-996-8710 or faxing the Prior Authorization Form to 330-996-8904. Forms may be
obtained from your provider manual or accessed online at www.summacare.com or www.apex-benefits.com.

INPAtIENt SERvICES
     •    Elective Inpatient Admissions
     •    Acute Inpatient Rehabilitation
     •    SNF, Transitional and Sub Acute Care
     •    Human Organ, Bone Marrow and Stem Cell Transplants


DIAGNOStIC tEStS
     •    Cat Scan (CT) with exception of CT of Sinus
     •    Magnetic Resonance Imaging (MRI, MRA, MRV)
     •    PET/SPECT
     •    Nuclear Cardiac Stress Procedures
     •	   Genetic	Testing
     •	   Echocardiograms


AMBULAtORY SERvICES
     •    Ambulance Services/Non-Emergent: Call 330-996-8791 or toll free 866-996-8791
     •    Durable Medical Equipment, Orthotics and Prosthetics: Call 330-996-8428 or toll free at 866-728-8797
     •    Hospice Care
     •    Pain Management (Initial request for an evaluation must be called in to the Benefits Determination Unit by the ordering
          physician. Additional visits must be prior authorized by the servicing provider.)


SERvICES REqUIRING DEtERMINAtION OF BENEFIt COvERAGE
     •    Potentially Cosmetic, Experimental or Investigational Procedures
     •    Infertility
     •    Sclerotherapy
     •    Provider administered injectibles and infusions (as listed on the attached page)
     •    Temporomandibular Joint Testing

Please contact the Provider Support Services Unit at 330-996-8400 or the Benefits Determination Unit at 330-996-8710 for specific CPt inquiries.
                                      PRIOR AUTHORIZATION LIST


Prior Authorization List
INjECtABLES AND INFUSIONS ADMINIStERED IN AN OFFICE OR OUtPAtIENt SEttING
The following is a list of injectables and infusions that require prior-authorization. SummaCare’s criteria for those drugs can be
viewed on our website at www.summacare.com. Please call 330-996-8805 to initiate the prior-authorization process.

AMEvIvE®

ARALASt®

BONIvA Iv®

CEREzYME®

CINRYzE®

FACtOR PRODUCtS

FLOLAN®

INFERtILItY INjECtIONS (Unless excluded by plan)

LUPRON® (No PA needed for oncology diagnoses)

ORENCIA®

RECLASt®

REMICADE® (No PA needed for Crohns disease)

RItUxAN® (No PA needed for oncology diagnoses)

SANDOStAtIN LAR®

SOLIRIS®

SYNAGIS®

thYROGEN®

tYSABRI®

xOLAIR®
Coverage decisions are based on plan benefits and appropriateness of care. This list is updated periodically. For the most current list, visit
www.medicare.summacare.com or contact SummaCare Secure Customer Service at 330-996-8885 or 800-996-6250 (TTY 800-750-0750). A customer
service representative will be available to take your call between 8 a.m. and 8 p.m. Monday through Friday.

CMS#H3660_09_96                                                                                                                     Revised 6/09