Preauthorization Requirement List Note: The following services, supplies and care must be preauthorized or reimbursement from the Plan may be reduced. To preauthorize services, your provider can contact Blue Cross Blue Shield at 833-468-3594. If preauthorization requirements are not met, covered expenses will be paid at 50% if the services are Medically Necessary and 0% if the services are not Medically Necessary. If you have any questions regarding medical preauthorization, call Blue Cross Blue Shield at 833-468-3594. » All Inpatient Admissions (Includes acute, Skilled, » Growth Hormones Rehabilitation, LTAC and Treatment Room Services) » Home Health » All Clinical Trials, Experimental & Investigational » Hyperbaric Oxygen Therapy Procedures/Treatment » Injectables (Boniva, Reclast, Hyalgan, Synagis, » All Transplant Services Including Pre-Transplant Orthovisc, Supartz, Botox, & Growth Hormones) Evaluations » Insulin Pump » All Out-of-Network and Out-of-Area Services, except » IV Infusions inpatient admissions, outpatient services, residential » Mental Health Services treatment, home health and hospice » All Plastic & Reconstructive Surgeries & Procedures » Orthotics and Prosthetics over $1,000 (with the exception of fracture or sprain diagnosis) (Cosmetic procedures are excluded from coverage) » All CT Scans and MRIs including CTAs and MRAs » PET Scans » 17 Alpha-Hydroxyprogesterone Caproate (17P) » Pain Management procedures » Alcohol/Substance Abuse » Podiatry treatment » Applied Behavior Analysis » Diagnostic studies and/or treatment of Sleep » Bariatric Surgery Disorders » Diabetic Education » Surgery (hysterectomy, varicose vein, nasal/septal » Durable Medical Equipment (purchases over $500 surgery, breast reduction, surgical intervention to correct sleep apnea, oral surgery) and all rentals) » Therapies – Physical, Speech, Occupational » Enteral Feedings » Non-Emergent Air Ambulance and Non-Emergent » Epidural Steroid Injections Ambulance Transportation » Genetic Studies/Testing/Therapy » Weight Loss Program & Medications (This list is not inclusive of all codes requiring prior authorizations; please contact Member Services for bene昀椀ts, eligibility, and code speci昀椀c requirements at 833-468-3594.) 28