UK-HMO
PRIOR PLAN APPROVAL LIST
Phone: (866) 776-4793
(Effective 7-1-2013)
The following Prior Plan Approval List represents services that require approval before the service is rendered. Failure to obtain prior
plan approval results in 100% penalty. No retro-authorizations are allowed.
Services
DME
 Bone Growth Stimulator: Electrical or Ultrasound
 External (Portable) Continuous Insulin Infusion
Pump
 Microprocessor Controlled Lower Limb Prosthesis


 Pneumatic Pressure Device with Calibrated Pressure
PROSTHETICS: Electronic or externally powered and
select other prosthetics


Communication Assisting/Speech Generating Devices
Functional Electrical Stimulation (FES); Threshold
Electrical Stimulation (TES)
Oscillatory Devices for Airway Clearance including
High Frequency Chest
Power Wheeled Mobility Devices
Standing Frame




Long-term Acute Care
Organ transplants/blood and marrow transplants

Physical rehabilitation facility admissions

Skilled Nursing Facility (SNF) admissions


Hospital inpatient admissions
Mental health and substance abuse facility
inpatient, partial hospital and intensive outpatient
services
Orthotics — professionally fitted braces and splints
costing more than $750
Prosthetics — artificial limbs

Procedures, tests and services


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
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


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Abdominoplasty
Benign skin lesion removal
Breast reduction/augmentation
*Hyperbaric Therapy
Molecular Diagnostic/Genetic Testing*
Non-participating Physician/Facility Requests
Plastic or cosmetic surgery
Sclerotherapy
Speech Therapy
Temporomandibular joint (TMJ) procedures



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Accidental dental and general anesthesia benefit
Blepharoplasty
Cochlear implant
Medication Preauthorization List (see page 2)
Neuropsychological testing
Oral surgery
Rhinoplasty
Septoplasty
Surgery for snoring or sleep apnea (e.g. UPPP)
Radiology
 Open MRIs outside UK or Samaritan Hospital (no open MRI at these facilities)
 Coronary CT angiography
1
UK-HMO Specialty Pharmacy Medical Management Drug List – Effective 7-1-2013
J0696
CODE
90281
90283
90284
90378
C9257
GENERIC NAME
TRADE
Immune Globulin-liquid 500mg
Immune globulin-liquid 500mg
Inflizximab 10mg
Imiglucerase 10 units
Laronidase 0.1mg
Flebogamma
IgIV
SCIg
Synagis
Avastin
J1572
J1599
J1745
J1786
J1931
Orencia
Eylea
Fabrazyme
Ceredase
Myozyme
Lumizyme
J2278
J2357
J2503
J2505
J2778
J2820
Ziconotide 1 mcg
Omalizumab 5 mcg
Pegaptanib 0.3 mg
Pedfilgrastim 6 mg
Ranibizumab 0.1 mg
Sargramostim 50 mcg
Aralast, Prolastin,
Zemaira
Glassia
Benlysta
Botox
Dysport
Myobloc
J2940
Somatrem 1 mg
J0257
J0490
J0585
J0586
J0587
Alpha 1 proteinase inhibitor
10mg
Alpha 1 proteinase inhibitor
Belimumab, 10 mg
Onabotulinum toxin A
Abobotulinum toxin A
Rimabotulinum toxin B
Prialt
Xolair
Macugen
Neulasta
Lucentis
Leukine,
Prokine
Protropin
J2941
J3262
J3385
J3490
J7321
J0588
Incobotulinumtoxin A
Xeomin
J7323
Multiple
Actemra
VPRIV
Elelyso
Hyalgan,
Supartz
Euflexxa
J0696
Ceftriaxone sodium (per 250mg)
Rocephine
J7324
J0881
Darbepoetin alfa, non-ESRD 1
mcg
Darbepoetin alfa, ESRD 1 mcg
Aranesp
J7325
Aranesp
J7326
J9010
Somatropin 1 mg
Tocilizumab
Velaglucerase alfa
Taliglucerase Alfa
Hyaluronic acid (No review if Dx is
related to knee)
Hyaluronic acid (No review if Dx is
related to knee)
Hyaluronic acid (No review if Dx is
related to knee)
Hyaluronic acid (No review if Dx is
related to knee
Hyaluronic acid (No review if Dx is
related to knee)
Alemtuzumab 10 mg
J9015
Aldesleukin
Proleukin
Flolan/Veletri
Neupogen
Neupogen
Naglazyme
Privigen
Gamastan
Gammaplex
Hizentra
J9035
J9055
J9228
J9264
J9303
J9305
J9310
J9355
Bevacizumab 10mg (C9257 is for
Cetuximab 10 mc
Ipilmumab
Paclitaxel protein-bound particles
Panitumumab 10 mg
Pemetrexed 10 mg
Rituximab 10mg
Trastuzumab 10mg
Avastin
Erbitux
Yervoy
Abraxane
Vectibix
Alimta
Rituxan
Herceptin
Gamastan
Gamunex
Vivaglobulin
Q2047
Q4074
Q4081
Peginesatide
Iloprost inhalation
Epoetin alfa, DRSD (dialysis 100
Omontys
Ventavis
Epogen,
Procrit
J0129
J0178
J0180
J0205
J0220
J0221
J0256
J0882
J0885
J0886
J1325
J1440
J1441
J1458
J1459
J1460
J1557
J1559
J1560
J1561
J1562
J1566
J1568
J1569
Immune globulin, IM
Immune globulin
Immune globulin 100mg SQ
Palivizumab 50mg
Bevacizumab 0.25mg (J9035 is
for 10 mg)
Abatacept 10mg
Afibercept 1mg
Agalsidase beta 1 mg
Alglucerase (per 10 units)
Alglucosidase Alfa, 10 mg
Alglucosidase Alfa, 10 mg
SPMM only reviews Rocephin for Lyme Disease
TRADE
CODE
GENERIC NAME
Epoetin alfa, non-esrd 1000
units
Epoetin alfa, ESRD (dialysis)
1000 units
Epoprostenol 0.5 mcg
Filgrastim 300 mcg
Filgrastim 480 mcg
Galsulfase 1 mg
Immune globulin-liquid 500mg
Gamma globulin, IM, 1cc
Immune globulin, liquid 500mg
Immune globulin Subcutaneous
(Human)
Gamma globulin, IM, over 10cc
Immune globulin-liquid 500mg
Immune globulin 100mg SQ
Immune globulin-powder
500mg
Immune globulin-liquid 500mg
Immune globulin-liquid 500 mg
Remicade
Cerezyme
Aldurazyme
Orthovisc
Synvisc
Synvisc-One
Gel-One
Campath
Epogen, Procrit
Octagam
Gammagard
2