2022 Prior Authorization List for Illinois

Providers: For the quickest turnaround on prior authorizations, use Availity. You can find the login link and instructions in the "Using Availity" section of our Providers page.

Members: Your provider usually handles prior authorizations for you. If you need any help, call us at 1-800-338-6833, TTY 711.

Note: For members with an Advocate Physician Partners (APP) PCP, referrals and authorizations will be managed by APP. Please work with the member's PCP to submit authorizations and referrals to APP.

The services and items listed below require prior authorization.

Behavioral Health

Contact our behavioral health partner, Magellan Healthcare (1-800-776-8684), about prior authorizations for:

• Electroconvulsive therapy (ECT)
• Transcranial magnetic stimulation (TMS)

Cardiac Devices

• Defibrillators (implantable)
• Left atrial appendage closure (LAAC) device, such as The Watchman
• Loop recorders
• Ventricular assist devices
• Wearable cardiac devices, such as Lifevest

Cardiac Diagnostic Testing

• Electrophysiology study (EPS)
• EPS with 3D mapping
• Myocardial perfusion imaging SPECT
• Nuclear stress test
• Transesophageal echocardiogram (TEE)

Cardiac Procedures and Surgeries

• Cardiac ablation
• Cardiac catheterizations (elective)
• Cardiac resynchronization therapy
• Outpatient coronary angioplasty/stent
• Transcatheter valve surgeries (TAVR)

Cosmetic and Plastic Surgery

• Abdominoplasty
• Blepharoplasty
• Breast procedures (except for mastectomy, reconstruction after mastectomy, and any cancer-related breast procedures)
• Gynecomastia surgery
• Panniculectomy and redundant skin tightening
• Rhinoplasty

Dental

In general, you don't need a prior authorization for dental care. We suggest that you always ask for a cost estimate before you receive dental services.

Diagnostic Imaging

• MRA
• MRI
• PET Scan
• SPECT

Durable Medical Equipment (DME)

The items listed below require prior authorization. Call us directly at 1-800-338-6833 (TTY 711) if you need any of the items below.

• Any DME that is not listed below and where the single purchase price or a rental over 13 months is more than $750
• Bariatric equipment (greater than 300 pounds)
• Bone growth stimulator
• Custom or specialized wheelchairs and scooters
• Neuromuscular stimulator
• Portable oxygen concentrator
• Prosthetic devices
• Specialty beds
• Ventilators covered by Medicare
• Wound vac

Home Healthcare

The services listed below require prior authorization. Call us directly at 1-800-338-6833 (TTY 711) if you need any of the services below:

• Home healthcare
• Home infusion

Inpatient Admissions

• Acute hospital
• Acute rehab facility
• Long-term acute care (LTAC)
• Skilled nursing facility (SNF)

Please contact our behavioral health partner, Magellan Healthcare (1-800-776-8684), about prior authorizations for:

• Mental health/Substance abuse
• Partial hospitalization (PHP)

Medicare Part B Drugs

Prior authorization list for Medicare Part B drugs

Observation

No prior authorization needed, but make sure to let us know about it.

Oncology

• Chemotherapy, supportive drugs, and symptom management drugs
• Radiation therapy

Other Surgery

• Cochlear and auditory brainstem implants
• Gender dysphoria surgery
• Obesity surgery, such as gastric bypass
• Oral, orthognathic, temporomandibular joint surgeries
• Orthopedic (hip, knee, shoulder arthroscopy)
• Surgery for obstructive sleep apnea
• Transplant surgeries
• Varicose veins: surgical treatment and sclerotherapy

Outpatient Diagnostic Testing

• Facility-based sleep studies (PSG)
• Infertility testing and treatment
• Molecular diagnostic and genetic testing

Outpatient Therapy

• Hyperbaric therapy

Spine

• Epidural injections (outpatient)
• Facet injections
• Kyphoplasty
• Neurostimulators
• Spinal cord stimulator
• Spinal decompression surgery
• Spinal fusion
• Vertebroplasty

Vision care

• Ophthalmologic services

Wound Therapy

• Negative pressure wound therapy (NPWT)

Other Services

• Experimental procedures, services, or devices
• Non-emergency ambulance services
• Out-of-network services and care (In most cases, members need to see in-network providers. But for special cases, they can request a prior authorization to see if we'll cover out-of-network care.)

No prior authorization needed for the following services, but make sure to let us know about them:

• Clinical trials
• Out-of-area dialysis at a Medicare-certified facility