UK-HMO

2015/16 PRIOR PLAN APPROVAL LIST

Phone: (866) 776-4793

(Effective 7-1-15)

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
/
  • Communication Assisting/Speech Generating Devices

  • External (Portable) Continuous Insulin Infusion Pump
/
  • Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)

  • Microprocessor Controlled Lower Limb Prosthesis
/
  • Oscillatory Devices for Airway Clearance including High Frequency Chest

  • Pneumatic Pressure Device with Calibrated Pressure
/
  • Power Wheeled Mobility Devices

PROSTHETICS: Electronic or externally powered and select other prosthetics /
  • Standing Frame

  • Hospital inpatient admissions
/
  • Long-term Acute Care

  • Mental health and substance abuse facility inpatient, partial hospital and intensive outpatient services
/
  • Organ transplants/blood and marrow transplants

  • Orthotics — professionally fitted braces and splints costing more than $750
/
  • Physical rehabilitation facility admissions

  • Prosthetics — artificial limbs
/
  • Skilled Nursing Facility (SNF) admissions

Procedures, tests and services
  • Abdominoplasty
/
  • Accidental dental and general anesthesia benefit (except anesthesia associated with wisdom teeth removal)

  • Benign skin lesion removal (Auths not required for UK Providers)
/
  • Blepharoplasty

  • Breast reduction/augmentation (Breast reconstruction procedures needs no precert with diagnosis of cancer)
/
  • Cochlear implant

  • *Hyperbaric Therapy
/
  • Medication Preauthorization List (see page 2)

  • Molecular Diagnostic/Genetic Testing*
/
  • Neuropsychological testing

  • Non-participating Physician/Facility Requests
/
  • Oral surgery (except wisdom teeth removal and associated anesthesia)

  • Plastic or cosmetic surgery
/
  • Rhinoplasty

  • Sclerotherapy (except stab phlebectomies)
/
  • Septoplasty

  • Speech Therapy
/
  • Surgery for snoring or sleep apnea (e.g. UPPP)

  • Temporomandibular joint (TMJ) procedures

Radiology
  • Open MRIs outside UK or Samaritan Hospital (no open MRI at these facilities)
  • Coronary CT angiography

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UK-HMO Specialty Pharmacy Medical Management Drug List – Effective 7-1-2015
CODE / GENERIC NAME / TRADE / CODE / GENERIC NAME / TRADE
90281 / Immune globulin, IM / J1572 / Immune Globulin-liquid 500mg / Flebogamma
90283 / Immune globulin / IgIV / J1599 / Immune globulin-liquid 500mg
90284 / Immune globulin 100mg SQ / SCIg / J1745 / Inflizximab 10mg / Remicade
90378 / Palivizumab 50mg / Synagis / J1786 / Imiglucerase 10 units / Cerezyme
C9257 / Bevacizumab 0.25mg (J9035 is for 10 mg) / Avastin / J1931 / Laronidase 0.1mg / Aldurazyme
J0129 / Abatacept 10mg / Orencia / J2278 / Ziconotide 1 mcg / Prialt
J0178 / Afibercept 1mg / Eylea / J2357 / Omalizumab 5 mcg / Xolair
J0180 / Agalsidase beta 1 mg / Fabrazyme / J2503 / Pegaptanib 0.3 mg / Macugen
J0205 / Alglucerase (per 10 units) / Ceredase / J2505 / Pedfilgrastim 6 mg / Neulasta
J0220 / Alglucosidase Alfa, 10 mg / Myozyme / J2778 / Ranibizumab 0.1 mg / Lucentis
J0221 / Alglucosidase Alfa, 10 mg / Lumizyme / J2820 / Sargramostim 50 mcg / Leukine, Prokine
J0256 / Alpha 1 proteinase inhibitor 10mg / Aralast, Prolastin, Zemaira / J2940 / Somatrem 1 mg / Protropin
J0257 / Alpha 1 proteinase inhibitor / Glassia / J2941 / Somatropin 1 mg / Multiple
J0490 / Belimumab, 10 mg / Benlysta / J3262 / Tocilizumab / Actemra
J0585 / Onabotulinum toxin A / Botox / J3385 / Velaglucerase alfa / VPRIV
J0586 / Abobotulinum toxin A / Dysport / J3490 / Taliglucerase Alfa / Elelyso
J0587 / Rimabotulinum toxin B / Myobloc / J7321 / Hyaluronic acid (No review if Dx is related to knee) / Hyalgan, Supartz
J0588 / Incobotulinumtoxin A / Xeomin / J7323 / Hyaluronic acid (No review if Dx is related to knee) / Euflexxa
J0881 / Darbepoetin alfa, non-ESRD 1 mcg / Aranesp / J7324 / Hyaluronic acid (No review if Dx is related to knee) / Orthovisc
J0882 / Darbepoetin alfa, ESRD 1 mcg / Aranesp / J7325 / Hyaluronic acid (No review if Dx is related to knee / Synvisc
Synvisc-One
J0885 / Epoetin alfa, non-esrd 1000 units / Epogen, Procrit / J7326 / Hyaluronic acid (No review if Dx is related to knee) / Gel-One
J0886 / Epoetin alfa, ESRD (dialysis) 1000 units / J9010 / Alemtuzumab 10 mg / Campath
J1325 / Epoprostenol 0.5 mcg / Flolan/Veletri / J9015 / Aldesleukin / Proleukin
J1440 / Filgrastim 300 mcg / Neupogen / J9035 / Bevacizumab 10mg (C9257 is for / Avastin
J1441 / Filgrastim 480 mcg / Neupogen / J9055 / Cetuximab 10 mc / Erbitux
J1458 / Galsulfase 1 mg / Naglazyme / J9228 / Ipilmumab / Yervoy
J1459 / Immune globulin-liquid 500mg / Privigen / J9264 / Paclitaxel protein-bound particles / Abraxane
J1460 / Gamma globulin, IM, 1cc / Gamastan / J9303 / Panitumumab 10 mg / Vectibix
J1557 / Immune globulin, liquid 500mg / Gammaplex / J9305 / Pemetrexed 10 mg / Alimta
J1559 / Immune globulin Subcutaneous (Human) / Hizentra / J9310 / Rituximab 10mg / Rituxan
J1560 / Gamma globulin, IM, over 10cc / Gamastan / J9355 / Trastuzumab 10mg / Herceptin
J1561 / Immune globulin-liquid 500mg / Gamunex / Q2047 / Peginesatide / Omontys
J1562 / Immune globulin 100mg SQ / Vivaglobulin / Q4074 / Iloprost inhalation / Ventavis
J1566 / Immune globulin-powder 500mg / Q4081 / Epoetinalfa, DRSD (dialysis 100 / Epogen, Procrit
J1568 / Immune globulin-liquid 500mg / Octagam
J1569 / Immune globulin-liquid 500 mg / Gammagard

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