Prior Authorization for Services

Prior Authorization means your doctor has requested permission for you to get a special service, referral or medication. We must approve these requests before the delivery of services. If you or your provider would like a referral to a service that is not a covered benefit, please call Member Services at 1-866-560-4042 (TTY/TDD: 711) so we can discuss other options available to you.

Some medical and behavioral health services may need Prior Authorization. For example, non‑emergency hospital admissions or others.

 

Below is a list of services that require prior authorization from Care1st before your healthcare provider can proceed with treatment. 

SERVICES THAT REQUIRE A PRIOR AUTHORIZATION

PRIOR AUTHORIZATION REQUIRED FOR SOME OR ALL OF THE SERVICES?

Behavioral Health Inpatient Facility

Yes

Behavioral Health Residential Facility

Some services require prior authorization

Home Care Training to Home Care Clients (HCTC)

Yes

Psychological and Neuropsychological Testing

Yes

Electroconvulsive Therapy (ECT)

Yes

Non‑emergency out of network services/treatments

Yes

Some medications, check the list of approved medications (formulary)

Some services require prior authorization

MRI, MRA, PET scans

Yes

Special lab work, genetics

Some services require prior authorization

Surgeries, pre-scheduled

Some services require prior authorization

Dialysis

Some services require prior authorization

Some Outpatient procedures and surgeries

Some services require prior authorization

Transplant

Some services require prior authorization

Bio pharmacy (Buy and Bill)

Some services require prior authorization

Criteria that decisions are based on are available upon request.

Outpatient Authorization and Drug Coverage forms can be found on our Member Handbooks and Forms page.