 |
|
Prior Authorization
Select Show/Hide to expand
the categories below.
Inpatient Hospital, Behavioral Health,
Chemical Dependency, Skilled Nursing, Rehabilitation -
Show/Hide
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
All Inpatient Hospital, Behavioral Health,
Chemical Dependency, Skilled Nursing, and Rehabilitation admissions
require Prior Authorization.
|
Medical Observation - Show/Hide
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
Medical Observation admits greater than
23 hrs require prior authorization.
|
Surgical Observation -
Show/Hide
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
Surgical Observation admits where the procedure
requires Prior Authorization.
|
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
Maternity admissions require Prior Authorization
under the following circumstances:
|
CPT®/HCPCS Code
|
Description
|
|
59400
59409
59410
59412
59414
|
Vaginal Delivery; > 48 hours from
delivery
|
|
59510
59514
59515
|
Cesarean Delivery; > 96 hours from
delivery
|
|
59610
59612
59614
|
Vaginal delivery after previous
cesarean section; > 48 hours from delivery
|
|
59618
59620
59622
|
Cesarean delivery following attempted
vaginal delivery after previous cesarean delivery; >
96 hours from delivery
|
|
Mental Health, Alcohol/Chemical
Dependency - Show/Hide
For Mental Health and Chemical Dependance
services please contact St. John's Mercy Managed Behavioral
Health at 314 729-4600 or 800 413- 8008
|
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
Home Health, except for Physical Therapy,
Occupational Therapy and Speech Therapy requires prior authorization.
|
Durable Medical Equipment -
Show/Hide
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
Durable Medical Equipment (DME) over $1000.00
single line item purchase price requires prior authorization.
In addition the following items, including but not limited to:
- Oxygen
- CPAP units
- TENS units
- Bone growth or neuromuscular stimulators
- Hopsital beds
- Wheelchairs
- Scooters
- All custom made items
- Insulin pumps
- Continuous Glucose Monitors
If a DME item needs repair and the repair
cost is $500.00 or more please contact Prior Authorization to
determine if the item should be repaired versus replaced.
|
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
Orthotics over $1000.00 requires prior authorization.
Any custom orthotic requires prior authorization.
|
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
Prosthetics over $1000.00 requires prior
authorization.
|
Non-emergent Ambulance Transfers,
Out-of-Network services, Requests for Benefit Exceptions -
Show/Hide
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
Non-emergent ambulance transfers, out-of-network
services, and requests for benefit exceptions requires prior
authorization.
|
All CPT codes ending in "99" -
Show/Hide
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
All CPT codes ending in "99" require prior
authorization.
|
All CPT codes ending in "T" -
Show/Hide
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
All CPT codes ending in "T" require prior
authorization.
|
Integumentary (skin) System -
Show/Hide
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
|
CPT®/HCPCS Code
|
Description
|
|
11920
11921
|
Tattooing, intradermal
|
|
11960
|
Insertion of tissue expander(s)
for other than breast, including subsequent expansion
|
|
11970
|
Replacement of tissue expander with
permanent prosthesis
|
|
11971
|
Removal of tissue expander(s) without
insertion of prosthesis
|
|
11975
11976
11977
|
Removal, insertion, and removal
with reinsertion, implantable contraceptive capsules
|
|
15822
15823
|
Blepharoplasty, upper eyelid
|
|
15840
15841
15842
15845
|
Graft for facial nerve paralysis;
free muscle graft; free muscle flap; regional muscle
transfer
|
|
15830
15847
|
Excision, excessive tissue skin
and subcutaneous tissue
|
|
19300
|
Mastectomy for gynecomastia
|
|
19316
|
Mastopexy
|
|
19318
|
Reduction mammaplasty
|
|
19324
19325
|
Mammaplasty, augmentation; with
and without prosthetic implant
|
|
19328
|
Removal of intact mammary implant
|
|
19330
|
Removal of mammary implant material
|
|
19340
19342
|
Immediate/ delayed insertion of
breast prosthesis following mastopexy, mastectomy, or
in reconstruction
|
|
19350
|
Nipple/ areola reconstruction
|
|
19380
19396
|
Revision of reconstructed breast;
preparation of moulage for custom breast implant
|
|
Q4100
Q4101
Q4102
Q4103
Q4104
Q4105
Q4106
Q4107
Q4108
Q4109
Q4110
Q4111
Q4112
Q4113
Q4114
Q4115
Q4116
|
Skin Substitute
|
|
Musculoskeletal System -
Show/Hide
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
|
CPT®/HCPCS Code
|
Description
|
|
20974
20975
|
Electrical stimulation to aid bone
healing; noninvasive; invasive
|
|
20979
|
Low intensity ultrasound stimulation
|
|
21010
|
Arthrotomy, temporomandibular joint
|
|
21050
21060
|
Condylectomy/Menisectomy; temporomandibular
joint
|
|
21070
|
Coronoidectomy
|
|
21076
21077
21079
21080
21081
21082
21083
21084
21085
21086
21087
21088
|
Impression and custom preparation;
maxillofacial prosthesis
|
|
21089
|
Unlisted maxillofacial prosthetic
procedure
|
|
21100
|
Application of halo type appliance
for maxillofacial fixation, includes removal
|
|
21110
|
Interdental fixation for other fracture
|
|
21116
|
Injection procedure for tempooromandibular
joint arthrography
|
|
21120
21121
21122
21123
|
Genioplasty
|
|
21125
21127
|
Augmentation, mandibular body or
angle; prosthetic material, with bone graft, onlay or
interpositional
|
|
21137
21138
21139
|
Reduction forehead
|
|
21141
21142
21143
21145
21146
21147
21150
21151
21154
21155
21159
21160
|
Reconstruction midface, LeFort I,
II, III
|
|
21172
21175
21179
21180
21181
21182
21183
21184
21188
21193
21194
21195
21196
|
Reconstruction of orbital rims,
forehead, cranial bones, mandibular
|
|
21198
|
Osteotomy, mandible, segmental;
with genioglossus advancement
|
|
21206
|
Osteoplasty,facial bones:augmentation
|
|
21208
|
Osteoplasty, facial bones; augmentation
|
|
21210
21215
21230
21235
|
Graft bone; nasal, maxillary or
malar areas; rib cartilage, ear cartilage
|
|
21240
21242
21243
|
Arthroplasty, temporomandiular joint;
autograft, allograft, prosthetic joint replacement
|
|
21244
21245
21246
21247
21248
21249
|
Reconstruction of mandible or maxilla
|
|
21255
|
Reconstruction of zygomatic arch
and glenoid fossa
|
|
21256
21260
21261
21263
21267
21268
|
Reconstruction of orbit with osteotomies;
periorbital osteotomies; orbital repositioning
|
|
21270
|
Malar augmentation, prosthetic material
|
|
21275
|
Secondary revision of orbitocraniofacial
reconstruction
|
|
21740
21742
21743
|
Reconstructive repair of pectus
excavatum or carinatum
|
|
22100
22101
22102
22103
22110
22112
22114
22116
|
Partial excision of vertebral body;
cervical, thoracic, lumbar, each additional segment
|
|
22137
22138
22139
|
Reduction forehead
|
|
22206
22207
22208
22210
22212
22214
22216
22220
22222
22224
22226
|
Osteotomy of spine; cervical, thoracic,
lumbar, each additional segment (including diskectomy)
|
|
22520
22521
22522
22523
22524
22525
|
Percutaneous vertebroplasty, kyphoplasty
|
|
22526
22527
|
Percutaneous annuloplasty
|
|
22548
22554
22556
22558
22585
22590
22595
22600
22610
22612
22614
22630
22632
22800
22802
22804
22808
22810
22812
|
Arthrodesis
|
|
22818
22819
|
Kyphectomy; single or more segments
|
|
22840
22841
22842
22843
22844
|
Posterior non-segmental, segmental
instrumentation
|
|
22845
22846
22847
|
Anterior Instrumentation
|
|
22848
|
Pelvic fixation other than sacrum
|
|
22849
|
Reinsertion of spinal fixation device
|
|
22850
|
Removal of posterior non-segmental
instrumentation (e.g. Harrington Rods)
|
|
22851
|
Application of intervertebral biomechanical
device to vertebral defect or interspace
|
|
22852
22855
|
Removal of posterior segmental;
anterior instrumentation
|
|
22856
22857
22861
22862
22864
22865
|
Total disc arthroplasty
|
|
22899
22999
|
Unlisted procedure spine, abdomen,
musculoskeletal system
|
|
28730
28731
28732
28733
28734
28735
28736
28737
28738
28739
28740
|
Arthrodesis
|
|
29867
|
Arthroscopy, knee, surgical; osteochondral
allograft (eg, mosaicplasty)
|
|
Respiratory System - Show/Hide
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
|
CPT®/HCPCS
Code
|
Description
|
|
30400
30410
30420
30435
30450
30460
30462
|
Rhinoplasty including major septal
repair
|
|
30465
|
Repair of nasal vestibluar stenosis
|
|
30520
30540
30545
30560
30580
30600
30620
30630
|
Septoplasty or submucous resection;
repair choanal atresia; lysis intranasal synechia; repair
fistula; dermatoplasty; repair nasal septal perforations
|
|
30999
|
Unlisted procedure, nose
|
|
Cardiovascular System -
Show/Hide
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
|
CPT®/HCPCS Code
|
Description
|
|
33282
|
Implantation of patient-activated
cardiac event recorder
|
|
33782
33783
|
Nikaidoh procedure
|
|
33981
33982
33983
|
Replace VAD
|
|
G0166
|
Enhanced External Counterpulsation
(35 treatments over 9 weeks)
|
|
C1764
|
Event recorder, cardiac (implantable)
|
|
E0616
|
Implantable cardiac event recorder
with memory, activator, and programmer
|
|
Digestive System - Show/Hide
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
|
CPT®/HCPCS Code
|
Description
|
|
41512
|
Tongue suspension
|
|
41530
|
Tongue based volume reduction
|
|
41800
41805
41806
|
Drainage of abscess, cyst, hematoma;
removal of embedded foreign body from dentoalveolar
structures
|
|
41820
41821
41822
41823
41825
41826
41827
41828
41830
41850
41870
41872
41874
|
Gingivectomy; operculectomy; excision
of tuberosities dentoalveolar structures; gingivoplasty
|
|
42140
|
Uvulectomy
|
|
42145
|
Palatopharyngoplasty
|
|
42280
|
Maxillary impression for palatal
prosthesis
|
|
42281
|
Insertion of pin-retained palatal
prosthesis
|
|
43281
43282
|
Lap paraesophageal hearnia repair
|
|
43647
43881
43882
|
Gastric neurostimulator electrodes,
implantation, revision, replacement, removal
|
|
43659
|
Unlisted laparoscopy, stomach
|
|
43770
43771
43772
43773
43774
43842
43843
43845
43846
43847
43848
|
Bariatric surgery
|
|
49411
|
placement of interstitial devices
for radiation therapy guidence
|
|
Reproductive System - Show/Hide
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
|
CPT®/HCPCS Code
|
Description
|
|
54400
54401
54405
54406
54408
54410
54411
54415
54416
54417
|
Penile prosthesis
|
|
58150
58152
58180
58200
58210
58240
|
Total abdominal hysterectomy, with
or without removal of tube(s) and/or ovary(s)
|
|
58951
|
Resection of ovarian, tubal, or
primary peritoneal malignancy with bilateral salpingo-oopherectomy
and omentectomy; with total abdominal hysterectomy,
pelvic and limited para-aortic lymphadenectomy
|
|
Nervous System - Show/Hide
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
|
CPT®/HCPCS Code
|
Description
|
|
61796
61797
61798
61800
|
Stereotactic radiosurgery, cranial
lesion
|
|
63620
63621
|
Stereotactic radiosurgery, spinal
lesion
|
|
63650
63655
63660
63661
63662
63663
63664
63665
63664
63665
63666
63667
63668
63669
63670
63671
63672
63673
63674
63675
63676
63677
63678
63679
63680
63681
63682
63683
63684
63685
63688
|
Neurostimulator spinal
|
|
64612
64613
64614
|
Chemodenervation of muscle(s); cervical
spinal muscle(s)
|
|
64622
64623
64626
64627
|
Destruction by neurolytic agent
|
|
64721
|
Neuroplasty and/or transposition;
median nerve at carpal tunnel
|
|
64910
64911
|
Nerve repair with synthetic conduit
or vein allograft
|
|
Eye & Ocular Adnexa - Show/Hide
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
|
CPT®/HCPCS Code
|
Description
|
|
65760
|
Keratomileusis
|
|
65771
|
Radial keratotomy
|
|
67221
67225
|
Photodynamic therapy
|
|
67311
67312
67313
67314
67315
67316
67317
67318
|
Strabismus surgery- for persons
18 and older
|
|
67345
|
Chemodenervation of extraocular
muscle
|
|
67909
67911
|
Reduction of ptosis
|
|
67912
|
Ocular surface reconstruction
|
|
67914
|
Repair of ectropian; repair of entropian
|
|
67915
|
Osseointegrated implant
|
|
67916
67917
67921
67922
67923
67924
|
Repair of ectrotion
|
|
69714
69715
|
Osseointegrated implant, implantation,
removal
|
|
69930
|
Cochlear device implantation, with
or without mastoidectomy
|
|
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
|
CPT®/HCPCS
Code
|
Description
|
|
70332
|
Temporomandibular joint arthrography
|
|
70554
70555
|
Functional MRI brain
|
|
72291
72292
|
Radiological supervision, vertebroplasty
|
|
74740
|
Hysterosalpingography
|
|
74742
|
Xray fallopian tubes
|
|
75552
75553
75554
75555
75556
76390
76805
76810
76811
76812
76813
76814
76815
76816
|
Cardiac MRI
|
|
76977
|
Bone density testing, < 50
years of age or > 1 every 2 years over age 50
|
|
77078
77079
|
CT Bone Densitometry
|
|
77080
77081
77082
G0130
|
DEXA Scans, all DEXA scans performed more frequently than once every two years
|
|
77301
|
Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications
|
|
77305
|
Teletherapy, isodose plan (whether hand or computer calculated); simple (1 or 2 parallel opposed unmodified ports directed to a single area of interest)
|
|
77310
|
Teletherapy, isodose plan (whether hand or computer calculated); intermediate (3 or more treatment ports directed to a single area of interest)
|
|
77315
|
Teletherapy, isodose plan (whether hand or computer calculated); complex (mantle or inverted Y, tangential ports, the use of wedges, compensators, complex blocking, rotational beam, or special beam considerations)
|
|
77321
|
Special teletherapy port plan, particles, hemibody, total body
|
|
77326
|
Brachytherapy isodose plan; simple (calculation made from single plane, 1 to 4 sources/ribbon application, remote afterloading brachytherapy, 1 to 8 sources)
|
|
77327
|
Brachytherapy isodose plan; intermediate (multiplane dosage calculations, application involving 5 to 10 sources/ribbons, remote afterloading brachytherapy, 9 to 12 sources)
|
|
77328
|
Brachytherapy isodose plan; complex (multiplane isodose plan, volume implant calculations, over 10 sources/ribbons used, special spatial reconstruction, remote afterloading brachytherapy, over 12 sources)
|
|
77331
|
Special dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating physician
|
|
77332
|
Treatment devices, design and construction; simple (simple block, simple bolus)
|
|
77333
|
Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special bolus)
|
|
77334
|
Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds or casts)
|
|
77336
|
Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy
|
|
77338
|
Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan
|
|
77370
|
Special medical radiation physics consultation
|
|
77371
77372
77373
G0339
G0340
|
Stereotactic radiation
|
|
77399
|
Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services
|
|
77418
|
Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session
|
|
78350
78351
|
Bone density; single or dual photon
|
|
78459
|
Myocardial imaging, positron emission
tomography (PET), metabolic evaluation
|
|
78491
78492
|
Myocardial imaging, positron emission
tomography (PET), single or multiple studies
|
|
78608
78609
78811
78812
78813
78814
78815
78816
|
Brain imaging, positron emission
tomography (PET); metabolic evaluation, perfusion evaluation
|
|
G0219
G0235
G0252
|
PET imaging
|
|
Pathology and Laboratory -
Show/Hide
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
|
CPT®/HCPCS Code
|
Description
|
|
83890
83891
83892
83893
83894
83895
83896
83897
83898
83899
83900
83901
83902
83903
83904
83905
83906
83907
83908
83909
83910
83911
83912
83913
83914
S3818
S3819
S3820
S3821
S3822
S3823
S3828
S3829
S3830
S3831
S3832
S3833
S3834
S3837
S3840
S3841
S3842
S3843
S3844
S3845
S3846
S3847
S3848
S3849
S3850
S3851
S3852
S3853
S3854
S3855
S3856
S3857
S3858
S3859
S3860
S3861
S3862
S3863
S3864
S3865
S3866
S3867
S3868
S3869
S3870
S3871
S3872
S3873
S3874
S3875
S3876
S3877
S3878
S3879
S3880
S3881
S3882
S3883
S3884
S3885
S3886
S3887
S3888
S3889
S3890
|
All Genetic and Molecular Testing
with the exception of Genetic
testing for Cystic Fibrosis, S3835.
|
|
Internal Medicine - Show/Hide
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
|
CPT®/HCPCS Code
|
Description
|
|
90875
90876
|
Individual psychophysiological therapy
incorporating
|
|
90901
90902
90904
90906
90908
90910
|
Biofeedback training by any modality
|
|
90911
|
Biofeedback training, perineal muscles,
anorectal or urethral sphincter, including EMG and/or
manometry
|
|
91110
|
GI tract imaging,intraluminla e.g.
capsule endoscopy
|
|
91111
|
GI tract imaging,intraluminla e.g.
capsule endoscopy
|
|
93228
93229
|
Wearable mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days
|
|
93701
|
Thoracic bioimpedance
|
|
96020
|
Neurofunctional testing
|
|
96118
96119
96120
|
Neuropsych testing
|
|
96150
96151
96152
96153
96154
96155
|
Health & behavior assessment/intervention
|
|
96567
|
Photodynamic therapy
|
|
96900
|
Actinotherapy (ultraviolet light)
|
|
96902
|
Microscopic examination of hair
plucked or clipped by the examiner
|
|
96910
96912
96913
|
Photochemotherapy (Goeckerman and/or
PUVA)
|
GI tract imaging,intraluminla e.g. capsule endoscopy
|
97532
|
Development of cognitive skills
|
|
97533
|
Sensory integrative techniques
|
|
97537
|
Community/work reintegration
|
|
97545
97546
|
Work hardening/conditioning
|
|
97605
97606
|
Negative pressure wound therapy
|
|
99183
|
Physician attendance and supervision
of hyperbaric oxygen therapy, per session
|
|
P9020
|
Platetlet Rich Plasma
|
|
s9055
|
Procuren or other growth factor
preparation to promote wound healing
|
|
Medications Requiring Authorization
- Medical Benefit - Show/Hide
Obtain precertification for the following
services by calling 800-330-8305 or 417-820-3182 or
download a Medication Exception Request form and fax to
the number on the top of the form.
All non-specific codes (i.e. J3490, J3590,
etc) will require NDC to be submitted on all claims prior to
payment. In addition, some medications billed with a non-specific
code may require prior authorization please call for assistance.
|
CPT®/HCPCS Code
|
Description
|
|
90378
|
RSV-IgIM, intramuscular, 50 mg
|
|
J0129
|
Injection, abatacept, 10 mg
|
|
J0180
|
Injection, agalsidase beta, 1 mg
|
|
J0205
|
Injection, alglucerase, per 10 units
|
|
J0220
|
Injection, alglucosidase alfa, 10
mg
|
|
J0256
|
Injection, alpha 1-proteinase inhibitor,
human, 10mg
|
|
J0348
|
Injection, anidulafungin, 1 mg
|
|
J0364
|
Injection, apomorphine hydrochloride,
1 mg
|
|
J0585
|
Botulinum toxin A, per unit
|
|
J0587
|
Botulinum Toxin Type B, per 100
units
|
|
J0594
|
Injection, busulfan, 1 mg
|
|
J0718
|
Injection, certolizumab pegol, 1
mg
|
|
J0894
|
Injection, decitabine, 1 mg
|
|
J1325
|
Injection, epoprostenol, 0.5 mg
|
|
J1458
|
Injection, galsulfase, 1 mg
|
|
J1459
|
Injection, immune globulin (Privigen),
intravenous, non-lyophilized (e.g liquid), 500 mg
|
|
J1460
J1470
J1480
J1490
J1500
J1510
J1520
J1530
J1540
J1550
J1560
|
Injection, gamma globulin, intramuscular
|
|
J1561
|
Injection, immune globulin, (Gamunex),
intravenous, non-lyophilized (e.g. liquid), 500 mg
|
|
J1562
|
Injection, immune globulin (Vivaglobin),
100 mg
|
|
J1566
|
Injection, immune globulin, intravenous,
lyophilized (e.g powder), not otherwise specified, 500
mg (Only Carimune NF, Panglobulin NF and Gammagard S/D
should be billed using this code)
|
|
J1568
|
Injection, immune globulin, (Octagam),
intravenous, non-lyophilized (e.g. liquid), 500 mg
|
|
J1569
|
Injection, immune globulin, (Gammagard),
intravenous, non-lyophilized, (e.g. liquid), 500 mg
|
|
J1571
|
Injection, hepatitis B immune globulin
(Hepagam B), intramuscular, 0.5 mL
|
|
J1572
|
Injection, immune globulin, (Flebogamma/Flebogamma
DIF), intravenous, non-lyophilized (e.g. liquid), 500
mg
|
|
J1573
|
Injection, hepatitis B immune globulin
(Hepagam B), intravenous, 0.5 mL
|
|
J1740
|
Injection, ibandronate sodium, 1
mg
|
|
J1743
|
Injection, idursulfase, 1 mg
|
|
J1745
|
Injection, infliximab, 10 mg
|
|
J1785
|
Injection, imiglucerase, per unit
|
|
J1931
|
Injection, laronidase, 0.1 mg
|
|
J2170
|
Injection, mecasermin, 1 mg 8
|
|
J2248
|
Injection, micafungin sodium, 1
mg
|
|
J2315
|
Injection, naltrexone, depot form,
1 mg
|
|
J2323
|
Injection, natalizumab, 1 mg
|
|
J2357
|
Injection, omalizumab, 5 mg
|
|
J2562
|
Injection, plerixafor (mozobil),
1 mg
|
|
J2724
|
Injection, protein C concentrate,
intravenous, human, 10 IU
|
|
J2791
|
Injection, Rho(D) immune globulin
(human), (Rhophylac), intramuscular or intravenous,
100 IU
|
|
J2793
|
Injection, Rilonacept (Arcalyst)),
1 mg
|
|
J2796
|
Injection, romiplostim (Nplate),
10 mcg
|
|
J3285
|
Inj treprostinil 1mg
|
|
J3465
|
Injection, voriconazole, 10 mg
|
|
J3488
|
Injection, zoledronic acid (Reclast),
1 mg
|
|
J7185
|
Injection, Factor VIII (Xyntha),
per IU
|
|
J7186
|
Injection, antihemophilic factor
VIII/Von Willebrand factor complex (human), per factor
VIII I.U.
|
|
J7187
|
Injection, Von Willebrand factor
complex (Humate-P), per IU, VWF:RCO
|
|
J7189
|
Factor VIIa (antihemophilic factor,
recombinant), per 1 microgram
|
|
J7190
|
Factor VIII (antihemophilic factor
[human]) per IU
|
|
J7192
|
Factor VIII (antihemophilic factor
[recombinant]) per IU
|
|
J7193
|
Factor IX (antihemophilic factor,
purified, non-recombinant) per IU
|
|
J7194
|
Factor IX, complex, per IU
|
|
J7195
|
Factor IX (antihemophilic factor,
recombinant) per IU
|
|
Q2023
|
Injection, factor VIII (antihemophilic
factor, recombinant) (Xyntha), per IU
|
|
J8501
|
Aprepitant, oral, 5 mg
|
|
J8650
|
Nabilone, oral, 1 mg
|
|
J9212
|
Injection, interferon Alfacon-1,
recombinant, 1 microgram
|
|
J9214
|
Injection, interferon, alfa-2b,
recombinant, 1 million units
|
|
J9215
|
Injection, interferon, alfa-n3,
(human leukocyte derived), 250,000 IU
|
|
J9216
|
Injection, interferon, gamma 1-b,
3 million units
|
|
Q4080
|
Iloprost, inhalation solution, FDA-approved
final product, non-compounded, administered through
DME, unit dose form, 20 micrograms
|
|
Q4081
|
Injection, epoetin alfa, 100 u
|
|
S0117
|
Tretinoin, topical, 5 grams
|
|
Medications Requiring Authorization
- Pharmacy Benefit - Show/Hide
Obtain precertification for the following
services by calling 800-647-2240 or 314-214-8282 or
download a Medication Exception Request form and fax to
the number on the top of the form.
|
Mercy MedicareADVANTAGE prescription
drug benefits...
[tier
2,
tier 4].
Commercial Outpatient Drug Formulary
Prior Authorization list. This list applies to all members
that are not enrolled in a MedicareADVANTAGE
Part D plan...
[more
on Non-MedicareADVANTAGE drug benefits]
Formulary drugs with a high potential
for misuse due to limited therapeutic indications, with
maximum dosing recommendations based on safety concerns,
or those drugs requiring extensive monitoring for side
effects may require prior authorization (PA) prior to
being covered. The PA process strives to ensure that
only the appropriate patients receive select therapies
through an appropriateness review against specific medical
criteria. Prior authorization criteria are defined by
the Formulary Management Committee. The following brand-name
products and generic versions, if available, require
prior authorization for coverage:
|
|
Medications
|
|
Actimmune
Actiq
Amitiza
Arava
Arcalyst
Avita (if member over 40 years old)
Baraclude
Brovana
Byetta
Campral
Copegus
Dexedrine/Dexedrine Spansule (if member over 18 years
old)
Emend
Emsam
Enbrel
Exjade
fentanyl - oral
Fentora
Flector
Floride Containing Vitamins and Minerals (if member
over 14 years old)
Forteo
Fuzeon
Gleevec
|
Growth Hormones (all)
Hepsera
Humira
Hycamtin
Increlex
Infergen
Infertility Medications (all injectables)
Intron A
Iressa
Kineret
Kuvan
Lamisil (tablets only)
Letairis
Nexavar
Noxafil
Opana ER
Pegasys
PEG-Intron
Promacta
Provigil
Qualaquin
Rebetol
Relistor
Restasis
Retin-A/Retin-A Micro (if member over 40 years old)Revatio
Revia
Revlimid
|
Ribapak
Ribasphere
Ribatab
ribavirin
Selzentry
Somatuline Depot
Sporonox
Sprycel
Strattera (if member is under 6 years of age)
Sutent
Symlin
Tasigna
Thalmid
Tracleer
Treximet
Tykerb
Tyzeka
Uloric
Vectical
Ventavis
Vfend
Voltaren gel
Xeloda
Xenazine
Xyrem
Zavesca
|
|
Obtain precertification for the following
services by calling 1-800-330-8305 or 417-820-3182.
Certain Procedures / Services are Excluded
from Coverage and other times those same Procedures / Services
may be covered. By calling us before you perform a particular
Procedure or Service, we can help to determine if it's excluded
for your patient, including, but not limited to:
- Dental
- Reconstructive / Cosmetic
- Experimental / Investigational
- Infertility
|
|
|
Please Note: Coverage determinations
may be based on plan documents and nationally recognized guidelines/criteria.
These include but are not limited to: Mercy Health Plans clinical policies,
The Centers for Medicare & Medicaid Services (CMS) guidelines and approved
compendia, and InterQual®.
CPT® codes and descriptions are copyright 2008 American
Medical Association. All rights reserved. CPT® is a registered trademark
of the American Medical Association (AMA).
|
|
|