Anesthesia (ACA)

00170, 00190,

Behavioral Health (ACA)

0362T, 0373T, 90867, 90868, 90869, 90870, 90899, 96116, 96121, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, G2067, G2068, G2069, G2070, G2071, G2073, G2074, G2075, G2076, G2077, G2078, G2079, G2080, H0008, H0009, H0010, H0011, H0012, H0013, H0014, H0015, H0017, H0018, H0019, H0035, H0046, H0047, H2013, H2035, H2036,

Dental (ACA)

D0364, D0365, D0366, D0367, D0368, D0369, D0380, D0381, D0382, D0383, D0384, D0385, D0423, D2960, D2961, D2962, D3428, D3429, D3460, D4263, D4264, D4275, D4276, D5913, D5914, D5915, D5916, D5919, D5922, D5923, D5924, D5925, D5926, D5927, D5928, D5929, D5931, D5932, D5933, D5934, D5935, D5936, D6010, D6011, D6012, D6013, D6040, D6050, D6051, D6052, D6055, D6057, D6058, D6059, D6060, D6061, D6062, D6063, D6064, D6065, D6066, D6067, D6068, D6069, D6070, D6071, D6072, D6073, D6074, D6075, D6076, D6077, D6080, D6082, D6083, D6084, D6085, D6086, D6087, D6088, D6090, D6091, D6095, D6096, D6097, D6098, D6099, D6100, D6103, D6104, D6110, D6111, D6112, D6113, D6114, D6115, D6116, D6117, D6118, D6119, D6120, D6121, D6122, D6123, D6985, D7340, D7350, D7840, D7850, D7852, D7854, D7856, D7858, D7860, D7865, D7873, D7874, D7875, D7876, D7877, D7940, D7941, D7943, D7944, D7945, D7946, D7947, D7948, D7949, D7950, D7951, D7952, D7953, D7955, D7960, D7963, D7995, D7996, D8010, D8020, D8030, D8040, D8050, D8060, D8070, D8080, D8090, D8210, D8220, D8670, D8680, D8681, D8690, D8695, D8696, D8697, D8698, D8699, D8701, D8702, D8703, D8704, D9222, D9223, D9239, D9243, D9248,

Durable Medical Equipment (DME) (ACA)

E0140, E0144, E0147, E0170, E0171, E0181, E0193, E0194, E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0270, E0277, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0300, E0301, E0302, E0303, E0304, E0316, E0328, E0329, E0371, E0372, E0373, E0466, E0467, E0480, E0481, E0482, E0483, E0484, E0486, E0500, E0574, E0575, E0601, E0616, E0619, E0621, E0627, E0629, E0635, E0636, E0637, E0650, E0651, E0652, E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0691, E0692, E0693, E0745, E0747, E0748, E0749, E0760, E0766, E0782, E0783, E0784, E0785, E0786, E0983, E0984, E0986, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1011, E1012, E1030, E1035, E1036, E1037, E1161, E1195, E1220, E1229, E1230, E1231, E1232, E1233, E1234, E1237, E1238, E1239, E1399, E1800, E1805, E1810, E1815, E1825, E2100, E2228, E2291, E2292, E2293, E2294, E2295, E2300, E2301, E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2340, E2341, E2342, E2343, E2351, E2361, E2362, E2363, E2364, E2365, E2366, E2367, E2368, E2369, E2370, E2371, E2372, E2373, E2374, E2375, E2376, E2377, E2378, E2397, E2402, E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2599, E2626, E2627, E2628, E2629, E2630, K0005, K0008, K0009, K0010, K0011, K0012, K0013, K0014, K0108, K0606, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898, K0899, S1034,

E&M (ACA)

99503, 99504, 99505, 99506, 99507, 99509, 99510, 99511, 99512, 99601,

Medical and Surgical Supplies (ACA)

A4210, A4264, A4290, A4555, A4559, A4600, A4606, A6023, A6025, A9274, A9606,

Medicine Services & Procedures (ACA)

0537T, 0538T, 0539T, 0540T, 91110, 91111, 93451, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93530, 93531, 93532, 93533, 93580, 93581, 93590, 93591, 93592, 95782, 95783, 95805, 95806, 95807, 95808, 95810, 95811, 95965, 95966, 95967, 97113, 99183, G0277, S2202, S9122, S9123, S9124,

Molecular and Genetic Testing (ACA)

0002M, 0003M, 0003U, 0005U, 0010U, 0012U, 0013U, 0014U, 0016U, 0017U, 0018U, 0021U, 0022U, 0023U, 0026U, 0027U, 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0036U, 0037U, 0040U, 0045U, 0046U, 0047U, 0048U, 0049U, 0050U, 0053U, 0055U, 0056U, 0067U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0084U, 0087U, 0089U, 0090U, 0092U, 0094U, 0101U, 0102U, 0103U, 0111U, 0113U, 0118U, 0129U, 0133U, 0169U, 0171U, 0172U, 0180U, 0181U, 0182U, 0183U, 0184U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U, 0201U, 81120, 81121, 81161, 81162, 81163, 81164, 81165, 81166, 81167, 81168, 81170, 81171, 81172, 81173, 81175, 81176, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81187, 81188, 81189, 81191, 81192, 81193, 81194, 81200, 81201, 81202, 81203, 81204, 81205, 81206, 81207, 81208, 81209, 81210, 81212, 81215, 81216, 81217, 81218, 81219, 81222, 81223, 81224, 81225, 81226, 81227, 81228, 81229, 81230, 81231, 81232, 81233, 81234, 81235, 81236, 81237, 81238, 81239, 81240, 81241, 81242, 81243, 81244, 81245, 81246, 81247, 81248, 81249, 81250, 81251, 81252, 81254, 81255, 81256, 81257, 81259, 81260, 81265, 81266, 81269, 81270, 81271, 81272, 81273, 81274, 81275, 81276, 81277, 81278, 81279, 81283, 81284, 81285, 81286, 81287, 81288, 81290, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81304, 81305, 81306, 81307, 81308, 81309, 81310, 81311, 81312, 81313, 81314, 81315, 81316, 81317, 81318, 81319, 81320, 81321, 81322, 81323, 81324, 81325, 81328, 81329, 81330, 81331, 81332, 81333, 81334, 81335, 81336, 81338, 81339, 81343, 81344, 81345, 81346, 81347, 81348, 81350, 81351, 81352, 81355, 81357, 81360, 81361, 81363, 81364, 81379, 81381, 81382, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81419, 81425, 81426, 81427, 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, 81440, 81442, 81443, 81445, 81448, 81450, 81455, 81460, 81465, 81470, 81471, 81479, 81500, 81503, 81504, 81518, 81519, 81520, 81521, 81522, 81525, 81529, 81538, 81539, 81540, 81542, 81545, 81546, 81551, 81552, 81595, 81599, 84999, 86849, 87901, 87903, 87904, 87906, 87999, 88240, 88241, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289, 88291, 88363, 89240, G9143, S3800, S3840, S3841, S3842, S3845, S3846, S3849, S3850, S3853, S3854, S3861, S3865, S3866, S3870,

Orthotic and Prosthetic Devices (ACA)

L1230, L1300, L1310, L1690, L1700, L1710, L1720, L1730, L1755, L1832, L1833, L1834, L1840, L1843, L1844, L1845, L1846, L1847, L1848, L1851, L1852, L1860, L1907, L1932, L1945, L1950, L1951, L1970, L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2050, L2060, L2090, L2280, L2330, L2340, L2350, L2510, L2520, L2525, L2526, L2540, L2570, L2580, L2627, L2628, L3330, L3763, L3764, L3765, L3766, L3900, L3901, L3904, L3905, L4030, L4205, L4631, L5000, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5500, L5505, L5610, L5611, L5613, L5614, L5616, L5617, L5618, L5620, L5622, L5624, L5626, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5845, L5848, L5856, L5857, L5858, L5859, L5920, L5930, L5940, L5950, L5960, L5961, L5962, L5964, L5966, L5968, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5986, L5987, L5988, L5990, L6026, L6050, L6055, L6100, L6110, L6120, L6130, L6200, L6205, L6250, L6300, L6310, L6320, L6350, L6360, L6370, L6400, L6450, L6500, L6550, L6570, L6611, L6621, L6623, L6624, L6625, L6628, L6638, L6646, L6647, L6648, L6677, L6686, L6687, L6688, L6689, L6690, L6692, L6693, L6694, L6695, L6696, L6697, L6698, L6704, L6707, L6708, L6709, L6711, L6712, L6713, L6714, L6715, L6721, L6722, L6880, L6881, L6882, L6895, L6900, L6905, L6910, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7181, L7185, L7186, L7190, L7191, L7259, L7364, L7366, L7400, L7404, L7405, L8049, L8510, L8600, L8605, L8609, L8614, L8619, L8627, L8628, L8630, L8631, L8658, L8659, L8679, L8680, L8681, L8682, L8683, L8684, L8685, L8686, L8687, L8688, L8689, L8690, L8691, L8692, L8693, L8694, L8695, L8696, L8701, L8702,

Outpt PPS (ACA)

C1721, C1722, C1767, C1772, C1778, C1787, C1816, C1820, C1822, C1840, C1882, C1883, C1891, C1897, C2626, C2634, C2635, C2636, C2637, C2639, C2640, C2641, C2642, C2643, C2645, C8921, C8922, C8923, C8924, C8925, C8926, C8928, C8929, C8930, C9359, C9362, C9484, C9487,

Pathology and Laboratory (ACA)

0001U, 0007U, 0011U, 0051U, 0054U, 0062U, 0063U, 0069U, 0078U, 0116U, 0121U, 0122U, 0143U, 0144U, 0145U, 0146U, 0147U, 0148U, 0149U, 0150U, 89354, 89356,

Radiology - eviCore (ACA)

70336, 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 70557, 70558, 70559, 71250, 71260, 71270, 71275, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72191, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 73200, 73201, 73202, 73206, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73700, 73701, 73702, 73706, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 74261, 74262, 74263, 74712, 74713, 75557, 75559, 75561, 75563, 75565, 75571, 75572, 75573, 75574, 75635, 76376, 76377, 76380, 76391, 76497, 76498, 77021, 77022, 77046, 77047, 77048, 77049, 77078, 77084, 78429, 78430, 78431, 78432, 78433, 78434, 78451, 78452, 78453, 78454, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78496, 78499, 78599, 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, 78999, C8900, C8901, C8902, C8903, C8905, C8906, C8908, C8909, C8910, C8911, C8912, C8913, C8914, C8918, C8919, C8920, C8931, C8932, C8933, C8934, C8935, C8936, G0235, G0252, G0297, S8035, S8037, S8042,

Radiology - Guiding Care (ACA)

0042T, 0342T, 0394T, 0395T, 0398T, 77301, 77338, 77371, 77372, 77373, 77385, 77386, 77422, 77423, 77424, 77425, 77432, 77435, 77469, 77520, 77522, 77523, 77525, 77770, 77771, 77772, 79403, C1715, C1716, C1717, C1719, C2616, C2638, C2644, C2698, C2699, C9725, C9734, G0339, G0340, G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014, G6015, G6016, S2095, S8092,

Surgery - Cardio, Hemic, & Lymphatic (ACA)

0345T, 0451T, 0452T, 0453T, 0454T, 0459T, 0483T, 0484T, 0543T, 0544T, 0569T, 0570T, 0571T, 0572T, 33240, 33249, 33254, 33255, 33256, 33270, 33274, 33275, 33340, 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33418, 33419, 33477, 33975, 33976, 33979, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848, 36260, 36465, 36466, 36468, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36483, 36511, 36516, 36522, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785,

Surgery - Digestive (ACA)

0184T, 42140, 42145, 43631, 43632, 43633, 43634, 43644, 43770, 43771, 43772, 43773, 43774, 43775, 43843, 43845, 43846, 43848, 43886, 43887, 43888, 44705, S2080,

Surgery - Eye and Ear (ACA)

66174, 66175, 66999, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911, 67950, 69300, 69710, 69714, 69715, 69717, 69718, 69930,

Surgery - Genital (ACA)

54120, 54125, 54130, 54135, 54400, 54401, 54405, 54408, 54410, 54411, 54416, 54417, 54520, 54660, 54690, 55175, 55180, 55400, 55970, 55980, 56620, 56625, 56800, 56805, 56810, 57106, 57107, 57109, 57110, 57111, 57112, 57291, 57292, 57335, 58150, 58180, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58672, 58673, 58720, 58750, 58752, 58760,

Surgery - Integumentary (ACA)

11443, 11920, 11921, 11922, 11950, 11951, 11952, 11954, 13152, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15769, 15775, 15776, 15777, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15819, 15820, 15821, 15822, 15823, 15824, 15825, 15826, 15828, 15829, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15840, 15841, 15842, 15847, 15876, 15877, 15878, 15879, 17106, 17107, 17108, 17360, 19300, 19303, 19316, 19318, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396,

Surgery - Musculoskeletal (ACA)

0095T, 0098T, 20930, 20931, 20936, 20937, 20938, 20974, 20975, 20979, 21050, 21060, 21070, 21120, 21121, 21122, 21123, 21125, 21127, 21137, 21138, 21139, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21172, 21175, 21179, 21180, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21215, 21230, 21235, 21240, 21242, 21243, 21244, 21245, 21246, 21247, 21248, 21249, 21255, 21270, 21280, 21282, 21685, 21740, 21742, 21743, 22100, 22101, 22102, 22110, 22112, 22114, 22206, 22207, 22210, 22214, 22216, 22220, 22222, 22224, 22510, 22511, 22512, 22513, 22514, 22515, 22533, 22534, 22548, 22551, 22554, 22556, 22558, 22586, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22849, 22853, 22854, 22855, 22856, 22858, 22861, 22864, 23130, 23410, 23412, 23415, 23420, 23470, 23472, 23473, 23474, 23800, 23802, 24100, 24101, 24102, 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 25332, 25441, 25442, 25443, 25444, 25446, 25447, 26531, 26536, 27096, 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, 27279, 27405, 27407, 27409, 27412, 27415, 27416, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27702, 27703, 28446, 29804, 29826, 29827, 29860, 29861, 29862, 29863, 29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29914, 29915, 29916, S2112, S2118,

Surgery - Nervous System (ACA)

0588T, 61624, 61630, 61796, 61797, 61798, 61799, 61800, 61863, 61864, 61867, 61868, 61870, 61885, 61886, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 62350, 62351, 62360, 62361, 62362, 62380, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63055, 63056, 63057, 63075, 63076, 63077, 63078, 63087, 63090, 63091, 63170, 63172, 63180, 63182, 63185, 63190, 63191, 63194, 63195, 63196, 63197, 63198, 63199, 63267, 63620, 63621, 63650, 63655, 63685, 64451, 64553, 64555, 64561, 64566, 64568, 64569, 64570, 64575, 64581, 64585, 64590, 64595, 64600, 64605, 64610, 64611, 64612, 64613, 64614, 64615, 64616, 64617, 64620, 64624, 64625, 64630, 64632, 64633, 64634, 64635, 64636, 64640, 64642, 64643, 64644, 64645, 64646, 64647, 64650, 64653, C1823,

Surgery - Renal and Urinary Tract (ACA)

53400, 53405, 53410, 53415, 53420, 53425, 53430, 53431, 53450, 53460,

Surgery - Respiratory (ACA)

30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30520, 30540, 30545, 30560, 30580, 30600, 30620, 30630, 32491,

Temp / Cat. II-III (ACA)

0355T, 0501T, 0502T, 0503T, 0504T, 4152F, G0069, G0151, G0152, G0153, G0155, G0156, G0157, G0158, G0159, G0160, G0161, G0166, G0299, G0300, G0429, G0448, G0455, G0458, G0460, G0493, G0494, G0495, G0496, Q0138, Q0139, Q1004, Q1005, Q3001, Q4074, Q4081, Q4101, Q4102, Q4105, Q4106, Q4107, Q4108, Q4114, Q4116, Q4122, Q4128, Q4132, Q4133, Q4145, Q4148, Q4151, Q4154, Q4176, Q4178, Q4179, Q4180, Q4181, Q4186, Q4187, Q5001, Q5002, Q5005, Q5006, Q5008, Q5010, Q9985, Q9991, Q9992, S0201, S2120, S2230, S2235, S2350, S2351, S3844, S5035, S5108, S5109, S5110, S5111, S5115, S5116, S5180, S5523, S9097, S9098, S9127, S9128, S9129, S9131, S9208, S9209, S9211, S9212, S9213, S9214, S9325, S9326, S9327, S9328, S9329, S9330, S9331, S9335, S9336, S9338, S9339, S9340, S9341, S9342, S9343, S9345, S9346, S9347, S9348, S9349, S9351, S9353, S9357, S9359, S9361, S9363, S9364, S9365, S9366, S9367, S9368, S9370, S9372, S9373, S9374, S9375, S9376, S9377, S9475, S9480, S9494, S9497, S9500, S9501, S9502, S9503, S9504, S9537, S9538, S9558, S9559, S9560, S9562, S9590, S9990, S9991, T1002, T1003, T1004, T1021, T1022, T1028, T1030, T1031, T2044, T2045,

Transplant (ACA)

0584T, 0585T, 0586T, 0587T, 32850, 32851, 32852, 32853, 32854, 32855, 32856, 33927, 33928, 33929, 33930, 33933, 33935, 33940, 33944, 33945, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230, 38232, 38240, 38241, 38242, 44132, 44133, 44135, 44136, 44137, 44715, 44720, 44721, 47133, 47135, 47140, 47141, 47142, 47143, 47144, 47145, 47146, 47147, 48160, 48550, 48551, 48552, 48554, 48556, 50300, 50320, 50323, 50325, 50327, 50328, 50329, 50340, 50360, 50365, 50370, 50380, 50547, S2053, S2054, S2055, S2060, S2061, S2065, S2102, S2140, S2142, S2150, S2152,

Vision and Hearing (ACA)

0308T, 0402T, S0515, V5095, V5298, V5299,

Professional Services - Care Mngmt (ACA)

G0076, G0077, G0078, G0079, G0080, G0081, G0082, G0083, G0084, G0085, G0086, G0087,

General Request for Elective Surgery, Procedure, Service or DME (ACA)

MEDICAL PA REQUEST,

Anesthesia (MA)

00170, 00190,

Behavioral Health (MA)

0362T, 0373T, 90870, 96116, 96121, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, H0008, H0009, H0010, H0011, H0012, H0013, H0015, H0035, H0046, H0047, H2013, H2035, H2036,

Durable Medical Equipment (DME) (MA)

E0140, E0144, E0147, E0170, E0171, E0181, E0193, E0194, E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0270, E0277, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0300, E0301, E0302, E0303, E0304, E0316, E0328, E0329, E0371, E0372, E0373, E0466, E0467, E0480, E0481, E0482, E0483, E0484, E0486, E0500, E0574, E0575, E0601, E0616, E0619, E0621, E0627, E0629, E0635, E0636, E0637, E0650, E0651, E0652, E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0691, E0692, E0693, E0745, E0747, E0748, E0749, E0760, E0766, E0782, E0783, E0784, E0785, E0786, E0983, E0984, E0986, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1011, E1012, E1030, E1035, E1036, E1037, E1161, E1195, E1229, E1230, E1231, E1232, E1233, E1234, E1237, E1238, E1239, E1800, E1805, E1810, E1815, E1825, E2100, E2228, E2291, E2292, E2293, E2294, E2295, E2300, E2301, E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2340, E2341, E2342, E2343, E2351, E2361, E2362, E2363, E2364, E2365, E2366, E2367, E2368, E2369, E2370, E2371, E2372, E2373, E2374, E2375, E2376, E2377, E2378, E2397, E2402, E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2599, E2626, E2627, E2628, E2629, E2630, K0005, K0008, K0009, K0010, K0011, K0012, K0013, K0014, K0108, K0606, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898,

E&M (MA)

99510,

Medical and Surgical Supplies (MA)

A4264, A4290, A4555, A4559, A4600, A4606, A6023, A6025, A9606,

Medicine Services & Procedures (MA)

0537T, 0538T, 0539T, 0540T, 91110, 91111, 93451, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93530, 93531, 93532, 93533, 93580, 93581, 93590, 93591, 93592, 95782, 95783, 95805, 95806, 95807, 95808, 95810, 95811, 95965, 95966, 95967, 97113, 99183, G0277,

Molecular and Genetic Testing (MA)

0002M, 0003M, 0005U, 0010U, 0012U, 0013U, 0014U, 0016U, 0017U, 0018U, 0022U, 0023U, 0034U, 0036U, 0040U, 0046U, 0048U, 0049U, 0050U, 0055U, 0056U, 0067U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0089U, 0090U, 0111U, 0118U, 0129U, 0133U, 0169U, 81120, 81121, 81161, 81162, 81163, 81164, 81165, 81166, 81167, 81170, 81171, 81172, 81173, 81175, 81176, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81187, 81188, 81189, 81200, 81201, 81202, 81203, 81204, 81205, 81206, 81207, 81208, 81209, 81210, 81212, 81215, 81216, 81217, 81218, 81219, 81222, 81223, 81224, 81225, 81226, 81227, 81228, 81229, 81230, 81231, 81232, 81233, 81234, 81235, 81236, 81237, 81238, 81239, 81240, 81241, 81242, 81243, 81244, 81245, 81246, 81247, 81248, 81249, 81250, 81251, 81252, 81254, 81255, 81256, 81257, 81259, 81260, 81265, 81266, 81269, 81270, 81271, 81272, 81273, 81274, 81275, 81276, 81277, 81283, 81284, 81285, 81286, 81287, 81288, 81290, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81304, 81305, 81306, 81307, 81308, 81310, 81311, 81312, 81313, 81314, 81315, 81316, 81317, 81318, 81319, 81320, 81321, 81322, 81323, 81324, 81325, 81328, 81329, 81330, 81331, 81332, 81333, 81334, 81335, 81336, 81343, 81344, 81345, 81346, 81350, 81355, 81361, 81363, 81364, 81379, 81381, 81382, 81400, 81401, 81402, 81403, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81425, 81426, 81427, 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81440, 81442, 81443, 81445, 81448, 81450, 81455, 81460, 81465, 81470, 81471, 81479, 81518, 81519, 81520, 81521, 81522, 81525, 81538, 81540, 81545, 81551, 81552, 81595, 81599, 84999, 87901, 87903, 87904, 87906, 88240, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289, G9143,

Orthotic and Prosthetic Devices (MA)

L1230, L1300, L1310, L1690, L1700, L1710, L1720, L1730, L1755, L1832, L1833, L1834, L1840, L1843, L1844, L1845, L1846, L1847, L1848, L1851, L1852, L1860, L1907, L1932, L1945, L1950, L1951, L1970, L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2050, L2060, L2090, L2280, L2330, L2340, L2350, L2510, L2520, L2525, L2526, L2540, L2570, L2580, L2627, L2628, L3330, L3763, L3764, L3765, L3766, L3900, L3901, L3904, L3905, L4030, L4205, L4631, L5000, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5500, L5505, L5610, L5611, L5613, L5614, L5616, L5617, L5618, L5620, L5622, L5624, L5626, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5845, L5848, L5856, L5857, L5858, L5859, L5920, L5930, L5940, L5950, L5960, L5961, L5962, L5964, L5966, L5968, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5986, L5987, L5988, L5990, L6026, L6050, L6055, L6100, L6110, L6120, L6130, L6200, L6205, L6250, L6300, L6310, L6320, L6350, L6360, L6370, L6400, L6450, L6500, L6550, L6570, L6611, L6621, L6623, L6624, L6625, L6628, L6638, L6646, L6647, L6648, L6677, L6686, L6687, L6688, L6689, L6690, L6692, L6693, L6694, L6695, L6696, L6697, L6698, L6704, L6707, L6708, L6709, L6711, L6712, L6713, L6714, L6715, L6721, L6722, L6880, L6881, L6882, L6895, L6900, L6905, L6910, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7181, L7185, L7186, L7190, L7191, L7259, L7364, L7366, L7400, L7404, L7405, L8049, L8510, L8600, L8605, L8609, L8614, L8619, L8627, L8628, L8630, L8631, L8658, L8659, L8679, L8680, L8681, L8682, L8683, L8684, L8689, L8691, L8693, L8694, L8695, L8696, L8701, L8702,

Outpt PPS (MA)

C1721, C1722, C1767, C1772, C1778, C1787, C1816, C1820, C1822, C1840, C1882, C1883, C1891, C1897, C2626, C2634, C2635, C2636, C2639, C2640, C2641, C2642, C2643, C2645, C9359, C9362,

Pathology and Laboratory (MA)

0007U, 0011U, 0051U, 0054U, 0062U, 0063U, 0069U, 0078U, 0116U, 0121U, 0122U, 0143U, 0144U, 0145U, 0146U, 0147U, 0148U, 0149U, 0150U,

Radiology - eviCore (MA)

70336, 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 70557, 70558, 70559, 71250, 71260, 71270, 71275, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72191, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 73200, 73201, 73202, 73206, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73700, 73701, 73702, 73706, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 74261, 74262, 74263, 74712, 74713, 75557, 75559, 75561, 75563, 75565, 75571, 75572, 75573, 75574, 75635, 76376, 76377, 76380, 76391, 76497, 76498, 77021, 77022, 77046, 77047, 77048, 77049, 77078, 77084, 78429, 78430, 78431, 78432, 78433, 78451, 78452, 78453, 78454, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78496, 78499, 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, 78999, C8900, C8901, C8902, C8903, C8905, C8906, C8908, C8909, C8910, C8911, C8912, C8913, C8914, C8918, C8919, C8920, C8931, C8932, C8933, C8934, C8935, C8936, G0235, G0297,

Radiology - Guiding Care (MA)

0042T, 0342T, 0394T, 0395T, 0398T, 77301, 77338, 77371, 77372, 77373, 77385, 77386, 77422, 77423, 77424, 77425, 77432, 77435, 77469, 77520, 77522, 77523, 77525, 77770, 77771, 77772, 79403, C1715, C1716, C1717, C1719, C2616, C2638, C2644, C2698, C2699, C9725, C9734, G0339, G0340, G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010, G6011, G6012, G6013, G6014, G6015, G6016, S2095,

Surgery - Cardio, Hemic, & Lymphatic (MA)

0345T, 0451T, 0452T, 0453T, 0454T, 0459T, 0483T, 0484T, 0543T, 0544T, 0569T, 0570T, 0571T, 0572T, 33240, 33249, 33254, 33255, 33256, 33270, 33274, 33275, 33340, 33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, 33369, 33418, 33419, 33477, 33975, 33976, 33979, 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848, 36260, 36465, 36466, 36468, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36483, 36511, 36516, 36522, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785,

Surgery - Digestive (MA)

0184T, 42140, 42145, 43631, 43632, 43633, 43634, 43644, 43770, 43771, 43772, 43773, 43774, 43775, 43843, 43845, 43846, 43848, 43886, 43887, 43888,

Surgery - Eye and Ear (MA)

66174, 66175, 66999, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911, 67950, 69300, 69714, 69715, 69717, 69718, 69930,

Surgery - Genital (MA)

54120, 54125, 54130, 54135, 54400, 54401, 54405, 54408, 54410, 54411, 54416, 54417, 54520, 54660, 54690, 55175, 55180, 55400, 55970, 55980, 56620, 56625, 56800, 56805, 56810, 57106, 57107, 57109, 57110, 57111, 57112, 57291, 57292, 57335, 58150, 58180, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58293, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58672, 58673, 58720, 58750, 58752, 58760,

Surgery - Integumentary (MA)

11443, 11920, 11921, 11922, 11950, 11951, 11952, 11954, 13152, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15769, 15775, 15776, 15777, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15819, 15820, 15821, 15822, 15823, 15824, 15825, 15826, 15828, 15829, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15840, 15841, 15842, 15847, 15876, 15877, 15878, 15879, 17106, 17107, 17108, 17360, 19300, 19303, 19316, 19318, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396,

Surgery - Musculoskeletal (MA)

0095T, 0098T, 20930, 20931, 20936, 20937, 20938, 20974, 20975, 20979, 21050, 21060, 21070, 21120, 21121, 21122, 21123, 21125, 21127, 21137, 21138, 21139, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21172, 21175, 21179, 21180, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21215, 21230, 21235, 21240, 21242, 21243, 21244, 21245, 21246, 21247, 21248, 21249, 21255, 21270, 21280, 21282, 21685, 21740, 21742, 21743, 22100, 22101, 22102, 22110, 22112, 22114, 22206, 22207, 22210, 22214, 22216, 22220, 22222, 22224, 22510, 22511, 22512, 22513, 22514, 22515, 22533, 22534, 22548, 22551, 22554, 22556, 22558, 22586, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22849, 22853, 22854, 22855, 22856, 22858, 22861, 22864, 23130, 23410, 23412, 23415, 23420, 23470, 23472, 23473, 23474, 23800, 23802, 24100, 24101, 24102, 24360, 24361, 24362, 24363, 24365, 24366, 24370, 24371, 25332, 25441, 25442, 25443, 25444, 25446, 25447, 26531, 26536, 27096, 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, 27279, 27405, 27407, 27409, 27412, 27415, 27416, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27702, 27703, 28446, 29804, 29826, 29827, 29860, 29861, 29862, 29863, 29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29914, 29915, 29916,

Surgery - Nervous System (MA)

0588T, 61624, 61630, 61796, 61797, 61798, 61799, 61800, 61863, 61864, 61867, 61868, 61870, 61885, 61886, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 62350, 62351, 62360, 62361, 62362, 62380, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63055, 63056, 63057, 63075, 63076, 63077, 63078, 63087, 63090, 63091, 63170, 63172, 63180, 63182, 63185, 63190, 63191, 63194, 63195, 63196, 63197, 63198, 63199, 63267, 63620, 63621, 63650, 63655, 63685, 64451, 64553, 64555, 64561, 64566, 64568, 64569, 64570, 64575, 64581, 64585, 64590, 64595, 64600, 64605, 64610, 64611, 64612, 64615, 64616, 64617, 64620, 64624, 64625, 64630, 64632, 64633, 64634, 64635, 64636, 64640, 64642, 64643, 64644, 64645, 64646, 64647, 64650, 64653, C1823,

Surgery - Renal and Urinary Tract (MA)

53400, 53405, 53410, 53415, 53420, 53425, 53430, 53431, 53450, 53460,

Surgery - Respiratory (MA)

30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30520, 30540, 30545, 30560, 30580, 30600, 30620, 30630, 32491,

Temp / Cat. II-III (MA)

0355T, 0501T, 0502T, 0503T, 0504T, G0069, G0151, G0152, G0153, G0155, G0156, G0157, G0158, G0159, G0160, G0161, G0166, G0299, G0300, G0429, G0448, G0455, G0458, G0460, G0493, G0494, G0495, G0496, Q0138, Q0139, Q1004, Q1005, Q3001, Q4074, Q4081, Q4101, Q4102, Q4105, Q4106, Q4107, Q4108, Q4114, Q4116, Q4122, Q4128, Q4132, Q4133, Q4145, Q4148, Q4151, Q4154, Q4176, Q4178, Q4179, Q4180, Q4181, Q4186, Q4187, Q5001, Q5002, Q5005, Q5006, Q5008, Q5010, Q9985, Q9991, Q9992,

Transplant (MA)

0584T, 0585T, 0586T, 0587T, 32850, 32851, 32852, 32853, 32854, 32855, 32856, 33927, 33928, 33929, 33930, 33933, 33935, 33940, 33944, 33945, 38204, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230, 38232, 38240, 38241, 38242, 44132, 44133, 44135, 44136, 44137, 44715, 44720, 44721, 47133, 47135, 47140, 47141, 47142, 47143, 47144, 47145, 47146, 47147, 48551, 48552, 48554, 48556, 50300, 50320, 50323, 50325, 50327, 50328, 50329, 50340, 50360, 50365, 50370, 50380, 50547,

Vision and Hearing (MA)

0308T, 0402T,

Professional Services - Care Mngmt (MA)

G0076, G0077, G0078, G0079, G0080, G0081, G0082, G0083, G0084, G0085, G0086, G0087,

General Request for Elective Surgery, Procedure, Service or DME (MA)

MEDICAL PA REQUEST,

Chiropractic services performed by an out-of-network provider

CHRIROPRACTIVE SERVICES,

Elective Pre-Operative Observation Status

ELECTIVE PRE OP OBSERVE,

Exceeding OT/PT/ST Benefit Limits for Developmental and Physical Disorders

EXCEEDING BENEFIT LIMITS,

General Request for Elective Surgery, Procedure, Service or DME

MEDICAL PA REQUEST,

All scheduled medical and surgical admissions

MEDICAL/SURGICAL ADMIT,

MRI ordered by a chiropractor

MRI BY A CHIROPRACTOR,

Out of network services for HMO members

OON SERVICES - HMO MEMBER,

Organ and Tissue Transplants (excluding cornea transplants)

ORGAN & TISSUE TRANSPLANT,

Behavioral Health

NDBH PA REQUEST,

Dental

D7940, D7941, D7943, D7944, D7945, D7946, D7947, D7948, D7949, D7950, D7995, D7996,

Durable Medical Equipment (DME)

E0486, E0745, E0747, E0748, E0749, E0760, E0766, E0782, E0783, E0784, E0785, E0786, E0983, E0984, E0986, E0988, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1011, E1017, E1018, E1035, E1036, E1161, E1220, E1226, E1227, E1229, E1230, E1231, E1232, E1233, E1234, E1239, E1296, E1298, E1399, E2300, E2301, E2311, E2312, E2313, E2323, E2325, E2326, E2331, E2351, E2361, E2375, E2377, E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2599, E2620, E2624, K0005, K0010, K0011, K0012, K0013, K0014, K0038, K0108, K0606, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898, K0899, S1040,

Medical and Surgical Supplies

A4290, A4555, A9274,

Medicine Services & Procedures

95805, 95808, 95810, 95811,

Molecular and Genetic Testing

0002M, 0003M, 0003U, 0005U, 0010U, 0012U, 0013U, 0014U, 0016U, 0017U, 0018U, 0021U, 0022U, 0023U, 0026U, 0027U, 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0036U, 0037U, 0040U, 0045U, 0046U, 0047U, 0048U, 0049U, 0050U, 0053U, 0055U, 0056U, 0067U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0087U, 0089U, 0090U, 0092U, 0094U, 0101U, 0102U, 0103U, 0111U, 0113U, 0118U, 0129U, 0133U, 0136U, 0234U, 81120, 81121, 81161, 81162, 81163, 81164, 81165, 81166, 81167, 81170, 81171, 81172, 81173, 81175, 81176, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81187, 81188, 81189, 81200, 81201, 81202, 81203, 81204, 81205, 81206, 81207, 81208, 81209, 81210, 81212, 81215, 81216, 81217, 81218, 81219, 81222, 81223, 81224, 81225, 81226, 81227, 81228, 81229, 81230, 81231, 81232, 81233, 81234, 81235, 81236, 81237, 81238, 81239, 81240, 81241, 81242, 81243, 81244, 81245, 81246, 81247, 81249, 81250, 81251, 81252, 81254, 81255, 81256, 81257, 81259, 81260, 81265, 81266, 81269, 81270, 81271, 81272, 81273, 81274, 81275, 81276, 81277, 81283, 81284, 81285, 81286, 81287, 81288, 81290, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81304, 81305, 81306, 81307, 81308, 81309, 81310, 81311, 81312, 81313, 81314, 81315, 81316, 81317, 81318, 81319, 81320, 81321, 81322, 81323, 81324, 81325, 81328, 81329, 81330, 81331, 81332, 81333, 81334, 81335, 81336, 81343, 81344, 81345, 81346, 81350, 81355, 81361, 81363, 81364, 81381, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81425, 81426, 81427, 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, 81440, 81442, 81443, 81445, 81448, 81450, 81455, 81460, 81465, 81470, 81471, 81479, 81500, 81503, 81504, 81518, 81519, 81520, 81521, 81522, 81525, 81538, 81539, 81540, 81542, 81545, 81551, 81552, 81595, 81599, 84999, 86849, 87901, 87903, 87904, 87906, 87999, 88104, 88240, 88241, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289, 88291, 88363, 89240, S3800, S3840, S3841, S3842, S3845, S3846, S3849, S3850, S3853, S3854, S3861, S3865, S3866,

Orthotic and Prosthetic Devices

97763, L5856, L5857, L5858, L5859, L5961, L6026, L6205, L6715, L6880, L6882, L6925, L6935, L6945, L6955, L6965, L6975, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7185, L7186, L7190, L7191, L7259, L7700, L8614, L8619, L8679, L8680, L8681, L8683, L8685, L8686, L8687, L8688, L8689, L8695, L8701,

Surgery - Cardio, Hemic, & Lymphatic

33975, 33976,

Surgery - Digestive

43644, 43770, 43771, 43772, 43773, 43774, 43775, 43843, 43845, 43846,

Surgery - Eye and Ear

67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 69930, L8615, L8616, L8617, S2235,

Surgery - Genital

55970, 55980,

Surgery - Musculoskeletal

20974, 20975, 20979, 21050, 21060, 21070, 21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21207, 21208, 21209, 21210, 21215, 21240, 21241, 21242, 21243, 21244, 21245, 21246, 21247, 21248, 21249, 22533, 22534, 22558, 22585, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22842, 22843, 22844, 22849, 22853, 22854, 22858, 22859, 22864, 22867, 22868, 22869, 22870, 27412, 27415, 27416, 28446, 29804, 29866, 29867, 63655, 63661, 63662, 63663, 63664, 63685, 63688,

Surgery - Respiratory

30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465,

Temp / Cat. II-III

0048T, 0049T, 0050T, 0195T, 0196T, 0439T, 0466T, 0467T, 0468T, S3844,

Vision and Hearing

S0515, V2531, V2627,

Intensity Modulated Radiation Therapy (IMRT)

77301, 77338, 77385, 77386, G6015, G6016,

Stereotactic Radiosurgery

77334, 77371, 77372, 77373, 77425, G0339, G0340,

Radiology

0042T, 0042T, 0439T, 0439T, 0609T, 0610T, 0611T, 0612T, 0633T, 0634T, 0635T, 0636T, 0637T, 0638T, 70336, 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71250, 71260, 71270, 71275, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72191, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 73200, 73201, 73202, 73206, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73700, 73701, 73702, 73706, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 74261, 74262, 74263, 74712, 74713, 75557, 75559, 75561, 75563, 75565, 75571, 75572, 75573, 75574, 75635, 76376, 76377, 76380, 76391, 76497, 76498, 77021, 77022, 77046, 77047, 77048, 77049, 77078, 77084, 77371, 77372, 77373, 78429, 78430, 78431, 78432, 78433, 78434, 78451, 78452, 78453, 78454, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78496, 78499, 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, 78999, 93303, 93304, 93306, 93307, 93308, 93312, 93313, 93314, 93315, 93316, 93317, 93350, 93351, 93352, 93356, C8900, C8901, C8902, C8903, C8904, C8905, C8906, C8907, C8908, C8909, C8910, C8911, C8912, C8913, C8914, C8918, C8919, C8920, C8921, C8922, C8923, C8924, C8925, C8926, C8928, C8929, C8930, G0235, G0252, G0339, G0340, S8035, S8037, S8042, S8092,

Radiopharmaceutical

A9513, C9031,

Surgery - Integumentary

15820, 15821, 15822, 15823, 19300, 19318, 19324, 19325,

Surgery - Nervous System

0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 61796, 61797, 61798, 61799, 61800, 61863, 61864, 61867, 61868, 61880, 61885, 61886, 61888, 62380, 63620, 63621, 63650, 64553, 64561, 64568, 64569, 64570, 64581, 64585, 64590, 64595, 64625, 64633, 64634, 64635, 64636, 95961, 95962, 95970, 95983, 95984,

Blepharoplasty

15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924, 67950,

Breast Surgery - Other Mastectomies and Related Procedures

19303, 19307, 19340, 19357, 19361, 19364, 19367, 19368, 19369,

Allografts & Bone Substitutes - Bone Substitutes & Related Items

C9359,

Cardiac Devices - Implantable Cardioverter Defibrillator (ICD)

C1721, C1722, C1882,

Cardiac Procedures - Cardiac Septal Defect; Atrial Transcatheter Closure

93580,

Cardiac Procedures - Electrophysiologic Study and Implantable Cardioverter Defibrillator Insertion

0571T, 33216, 33217, 33225, 33249, 33270, 93619, 93620, 93621, 93622, 93624, 93640, 93641, 93642,

Hysterectomies - Total Laparoscopic Hysterectom

58541, 58542, 58543, 58544, 58548, 58550, 58552, 58553, 58554, 58571, 58572, 58573, 58575,

Hysterectomies - Vaginal Hysterectomy

58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58293, 58294,

Miscellaneous - Panniculectomy

15830,

Miscellaneous - Skin & Skin Substitutes

Q4101, Q4102, Q4105, Q4106, Q4107, Q4116, Q4128, Q4132, Q4133, Q4145, Q4148,

Neurostimulators - Peripheral Nerve Stimulators

61888, 64555, 64575, 95970, 95971, 95972, 95976, 95977, C1767, C1778, C1787, C1816, C1820, C1822, C1823, C1883, C1897, E0720, E0730,

Orthopedic Procedures - Hip (Arthroscopy & Arthroplasty)

27125, 27130, 27132, 27134, 27137, 27138, 29861, 29862, 29863, 29914, 29915, 29916,

Orthopedic Procedures - Knee (Arthroscopy & Arthroplasty)

27445, 27446, 27447, 27486, 27487, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889,

Orthopedic Procedures - Shoulder Arthroscopy, Acromioplasty & Rotator Cuff Repair

23130, 23410, 23412, 23415, 23420, 29826, 29827,

ENT Procedures - Septoplasty

30520,

ENT Procedures - Uvulopalatopharyngoplasty

42145,

Spinal Procedures - Anterior Arthrodesis of the Spine

22548, 22551, 22552, 22554, 22585,

Spinal Procedures - Cervical Diskectomy, Microdiskectomy, Foraminotomy, Laminotomy

63020, 63035, 63040, 63043, 63045, 63048, 63075, 63076,

Spinal Procedures - Cervical Disk Arthroplasty

0098T, 22856, 22861, 22864,

Intrathecal Pump Implantation

62350, 62351, 62360, 62361, 62362,

If you see a procedure or code is required, use the get started button on this page to submit a request.

For a period of time, you can still submit new requests using the legacy online process below.

Requests for Commercial Plan Members
Commercial Blue KC Prior Authorization Form

For a period of time, you can submit new requests using the Blue KC online process below.

Requests for MA/ACA Plan Members
MA/ACA Blue KC Prior Authorization Form
Radiology Services

You may also submit requests by fax or mail. Please include any supporting medical information in your request. Check the status of an existing request using the customer service number listed on the member ID card.

Fax Requests for Commercial Plan Members
816-926-4253

Mail-in Requests for Commercial Plan Members
Blue Cross and Blue Shield of Kansas City
Attention: Prior Authorization, Mail Stop B5A1
P.O. Box 411878
Kansas City, MO 64141-1878

Fax Requests for ACA and Medicare Advantage Plan Members
877-549-1744

Mail-in Requests for ACA and Medicare Advantage Plan Members
Central Operations (COPS) Blue KC MA & ACA
P.O. Box 419169
Kansas City, MO 64141

Affordable Care Act Forms (PDF)
You can also submit prior authorization requests using these specific forms:
Services, DME, prostheses
Radiology Services

The member ID for someone in an Individual and Family ACA Plan will begin with one of the following prefixes:
YBD, YBG, YBS, YBM, YBT, YBX, YJV, YJW, YJJ or YJT

Medicare Advantage Forms (PDF)
You can also submit prior authorization requests using these specific forms:
Services, DME, prostheses
Radiology Services

The member ID for a Medicare Advantage member will begin with a prefix of RRK or RKN.

• Respiratory Syncytial Virus Immune Globulin
• Lutetium Lu 177 Dotatate Therapeutic 1 Mci
• Abatacept Injection
• Injection Agalsidase Beta 1 Mg
• Injection Alemtuzumab 1 Mg
• Lumizyme Injection
• Alpha 1 Proteinase Inhibitor
• Glassia Injection
• Belimumab Injection
• Injection Cerliponase Alfa 1 Mg
• Injection Lanadelumab-Flyo 1 Mg
• Inj C1 Esterase Inhib Ruconest 10 U
• C-1 Esterase Berinert
• C-1 Esterase Cinryze
• Injection C-1 Esterase Inhibitor 10 Units
• Injection Etelcalcetide 0.1 Mg
• Canakinumab Injection
• Collagenase Clost Hist Inj
• Inj Corticotropin To 40 Units
• Denosumab Injection
• Ecallantide Injection
• Eculizumab Injection
• Injection Edaravone 1 Mg
• Elosulfase Alfa Injection
• Inj Epoprostenol 0.5 Mg
• Inj Ivig Privigen 500 Mg
• Inj Gamma Globulin Im 1 Cc
• Injection Immune Globulin 100 Mg
• Inj Imm Glob Bivigam 500Mg
• Gammaplex Injection
• Hizentra Injection
• Inj Gamma Globulin Im Over 10 Cc
• Gamunex-C/Gammaked
• Immune Globulin Powder
• Octagam Injection
• Gammagard Liquid Injection
• Flebogamma Injection
• Inj Ig/Hyaluronidase 100 Mg Ig
• Ivig Non-Lyophilized Nos
• Golimumab For Iv Use 1Mg
• Idursulfase Injection
• Inj Infliximab Excl Biosimilr 10 Mg
• Imuglucerase Injection
• Injection Laronidase 0.1 Mg
• Injection Mepolizumab 1Mg
• Natalizumab Injection
• Injection Nusinersen 0.1 Mg
• Injection Ocrelizumab 1 Mg
• Injection Omalizumab 5 Mg
• Pegloticase Injection
• Plerixafor Injection
• Romiplostim Injection
• Injection Romosozumab-Aqqg 1 Mg
• Tocilizumab Injection
• Injection Treprostinil 1 Mg
• Ustekinumab Intravenous Inj 1 Mg
• Injection Vedolizumab 1 Mg
• Velaglucerase Alfa
• Injection Emicizumab-Kxwh 0.5 Mg
• Inj Factor X (Human) 1Iu
• Injection Human Fibrinogen Concentrate 1 Mg
• Injection Human Fibrinogen Conc Nos 1 Mg
• Vonvendi Inj 1 Iu Vwf:Rco
• Factor Xiii Anti-Hem Factor
• Factor Xiii Recomb A-Subunit
• Factor Viii Recomb Novoeight
• Wilate Injection
• Xyntha Inj
• Antihemophilic Viii Vwf Comp
• Humate-P Inj
• Injection Factor Viii Per I.U.
• Factor Viia Antihemophilic Factor Recombinant /1 Microgram
• Factor Viii (Anti-Hemophilic Factor Human)Per Iu
• Factor Viii Recombinant Nos
• Factor Ix (Antihemophilic Factor Purified Non-Recombinant) Per I.U.
• Factor Ix Complx Per Iu
• Factor Ix Recombinant Nos
• Antithrombin Iii (Human) Per Iu
• Anti-Inhibitor Per I.U.
• Hemophilia Clotting Factor Noc
• Factor Ix Recombinan Rixubis
• Inj Factor Ix Fc Fus Protein Per Iu
• Factor Ix Idelvion Inj
• Injection Factor Ix Glycopegylated 1 Iu
• Inj Factor Viii Fc Fusion Per Iu
• Factor Viii Pegylated Recomb
• Injection Factor Viii Pegylated-Aucl 1 Iu
• Factor Viii Nuwiq Recomb 1Iu
• Inj Factor Viii Afstyla 1 I.U.
• Inj Factor Viii Kovaltry 1 I.U.
• Orthovisc Inj Per Dose
• Injection Avelumab 10 Mg
• Injection Bevacizumab 10 Mg
• Injection Blinatumomab 1 Microgram
• Injection Copanlisib 1 Mg
• Injection Liposomal 1 Mg Dnr And 2.27 Mg Ca
• Injection Durvalumab 10 Mg
• Inj Gemtuzumab Ozogamicin 0.1 Mg
• Injection Mogamulizumab-Kpkc 1 Mg
• Injection Emapalumab-Lzsg 1 Mg
• Ipilimumab Injection
• Injection Inotuzumab Ozogamicin 0.1 Mg
• Injection Tagraxofusp-Erzs 10 Mcg
• Injection Pertuzumab 1 Mg
• Injection Polatuzumab Vedotin-Piiq 1 Mg
• Injection Rituximab 10 Mg And Hyaluronidase
• Injection Rituximab 10 Mg
• Inj Ado-Trastuzumab Emt 1Mg
• Injection Trastuzumab Excludes Biosimilar 10 Mg
• Tisagenlecleucel To 600 M Car-Pos Vi T Ce Per Td
• Sipleucel-T Auto Cd54+
• Injection, Inflectra
• Injection Bevacizumab-Awwb Biosimilar 10 Mg
• Inj Pegflgrstm-Jmdb Biosimlr 0.5 Mg
• Ogivri (Trastuzumab)
• Truxima Injection
• Kanijnti Injection
• Lutetium Lu 177 Dotatate Ther 1 Mci
• Givlaari (givosiran)
• Inj Ceftriaxone Sodium Per 250 Mg
• Adakveo (crizanlizumab)
• Vyondys-53 (golodirsen)
• Xembify (immune globulin)
• Injection Guselkumab 1 Mg
• Zolgensma (onasemnogene abeparvoveck-xioi)
• Injection Calaspargase Pegol-Mknl 10 Units
• Injection Cemiplimab-Rwlc 1 Mg
• Unclassified Drugs
• Unclassified Biologics
• Injection Elotuzumab 1Mg
• Injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg
• Injection, trastuzumab-qyyp, biosimilar, (Trazimera), 10 mg
• Injection, rituximab-pvvr, biosimilar, (Ruxience), 10 mg

• Respiratory Syncytial Virus Immune Globulin
• Lutetium Lu 177 Dotatate Therapeutic 1 Mci
• Abatacept Injection
• Injection Agalsidase Beta 1 Mg
• Injection Alemtuzumab 1 Mg
• Lumizyme Injection
• Alpha 1 Proteinase Inhibitor
• Glassia Injection
• Belimumab Injection
• Injection Cerliponase Alfa 1 Mg
• Injection Lanadelumab-Flyo 1 Mg
• Inj C1 Esterase Inhib Ruconest 10 U
• C-1 Esterase Berinert
• C-1 Esterase Cinryze
• Injection C-1 Esterase Inhibitor 10 Units
• Injection Etelcalcetide 0.1 Mg
• Canakinumab Injection
• Collagenase Clost Hist Inj
• Inj Corticotropin To 40 Units
• Denosumab Injection
• Ecallantide Injection
• Eculizumab Injection
• Injection Edaravone 1 Mg
• Elosulfase Alfa Injection
• Inj Epoprostenol 0.5 Mg
• Inj Ivig Privigen 500 Mg
• Inj Gamma Globulin Im 1 Cc
• Injection Immune Globulin 100 Mg
• Inj Imm Glob Bivigam 500Mg
• Gammaplex Injection
• Hizentra Injection
• Inj Gamma Globulin Im Over 10 Cc
• Gamunex-C/Gammaked
• Immune Globulin Powder
• Octagam Injection
• Gammagard Liquid Injection
• Flebogamma Injection
• Inj Ig/Hyaluronidase 100 Mg Ig
• Ivig Non-Lyophilized Nos
• Golimumab For Iv Use 1Mg
• Idursulfase Injection
• Inj Infliximab Excl Biosimilr 10 Mg
• Imuglucerase Injection
• Injection Laronidase 0.1 Mg
• Injection Mepolizumab 1Mg
• Natalizumab Injection
• Injection Nusinersen 0.1 Mg
• Injection Ocrelizumab 1 Mg
• Injection Omalizumab 5 Mg
• Pegloticase Injection
• Plerixafor Injection
• Romiplostim Injection
• Injection Romosozumab-Aqqg 1 Mg
• Tocilizumab Injection
• Injection Treprostinil 1 Mg
• Ustekinumab Intravenous Inj 1 Mg
• Injection Vedolizumab 1 Mg
• Velaglucerase Alfa
• Injection Emicizumab-Kxwh 0.5 Mg
• Inj Factor X (Human) 1Iu
• Injection Human Fibrinogen Concentrate 1 Mg
• Injection Human Fibrinogen Conc Nos 1 Mg
• Vonvendi Inj 1 Iu Vwf:Rco
• Factor Xiii Anti-Hem Factor
• Factor Xiii Recomb A-Subunit
• Factor Viii Recomb Novoeight
• Wilate Injection
• Xyntha Inj
• Antihemophilic Viii Vwf Comp
• Humate-P Inj
• Injection Factor Viii Per I.U.
• Factor Viia Antihemophilic Factor Recombinant /1 Microgram
• Factor Viii (Anti-Hemophilic Factor Human)Per Iu
• Factor Viii Recombinant Nos
• Factor Ix (Antihemophilic Factor Purified Non-Recombinant) Per I.U.
• Factor Ix Complx Per Iu
• Factor Ix Recombinant Nos
• Antithrombin Iii (Human) Per Iu
• Anti-Inhibitor Per I.U.
• Hemophilia Clotting Factor Noc
• Factor Ix Recombinan Rixubis
• Inj Factor Ix Fc Fus Protein Per Iu
• Factor Ix Idelvion Inj
• Injection Factor Ix Glycopegylated 1 Iu
• Inj Factor Viii Fc Fusion Per Iu
• Factor Viii Pegylated Recomb
• Injection Factor Viii Pegylated-Aucl 1 Iu
• Factor Viii Nuwiq Recomb 1Iu
• Inj Factor Viii Afstyla 1 I.U.
• Inj Factor Viii Kovaltry 1 I.U.
• Orthovisc Inj Per Dose
• Injection Avelumab 10 Mg
• Injection Bevacizumab 10 Mg
• Injection Blinatumomab 1 Microgram
• Injection Copanlisib 1 Mg
• Injection Liposomal 1 Mg Dnr And 2.27 Mg Ca
• Injection Durvalumab 10 Mg
• Inj Gemtuzumab Ozogamicin 0.1 Mg
• Injection Mogamulizumab-Kpkc 1 Mg
• Injection Emapalumab-Lzsg 1 Mg
• Ipilimumab Injection
• Injection Inotuzumab Ozogamicin 0.1 Mg
• Injection Tagraxofusp-Erzs 10 Mcg
• Injection Pertuzumab 1 Mg
• Injection Polatuzumab Vedotin-Piiq 1 Mg
• Injection Rituximab 10 Mg And Hyaluronidase
• Injection Rituximab 10 Mg
• Inj Ado-Trastuzumab Emt 1Mg
• Injection Trastuzumab Excludes Biosimilar 10 Mg
• Tisagenlecleucel To 600 M Car-Pos Vi T Ce Per Td
• Sipleucel-T Auto Cd54+
• Injection, Inflectra
• Injection Bevacizumab-Awwb Biosimilar 10 Mg
• Inj Pegflgrstm-Jmdb Biosimlr 0.5 Mg
• Ogivri (Trastuzumab)
• Truxima Injection
• Kanijnti Injection
• Spl Radophrm Tx Imag Agt Noc
• Injection, Brexanolone, 1Mg
• Kcentra, Per I.U.
• Aflibercept Injection
• Injection Brolucizumab-Dbll 1 Mg
• Alglucosidase Alfa Injection
• Injection Patisiran 0.1 Mg
• Injection Benralizumab 1 Mg
• Injection Bezlotoxumab 10 Mg
• Buprenorphine Implant 74.2Mg
• Injection Burosumab-Twza 1 Mg
• Injection Onabotulinumtoxina
• Abobotulinumtoxina
• Inj Rimabotulinumtoxinb
• Incobotulinumtoxin A
• Certolizumab Pegol Inj 1Mg
• Injection Darbepoetin Alfa 1 Microgram Non-Esrd Use
• Injection Darbepoetin Alfa 1 Microgram For Esrd On Dialysis
• Injection Epoetin Alfa For Non-Esrd Use 1000 Units
• Epoetin Beta Esrd Use
• Epoetin Beta Non Esrd
• Injection Ravulizumab-Cwvz 10 Mg
• Injection Eteplirsen 10 Mg
• Inj Ferric Carboxymaltos 1Mg
• Inj Filgrastim Excl Biosimil
• Injection Tbo-Filgrastim 1 Microg
• Injection Galsulfase 1 Mg
• Injection Glatiramer Acetate 20 Mg
• Injection Hpc 10 Mg
• Injection Hpc Nos 10 Mg
• Interferon Beta-1A Inj
• Interferon Beta-1B Per 0.25 Mg Admin Phys Superv
• Lanreotide Injection
• Inj Leuprolide Acetate Per 3.75 Mg
• Injection Octreotide Depot Form For Intramuscular Injection
• Inj Octreotide Non-Depot Form For Subctns Or Intrvns Inj 25 Mg
• Inj Pasireotide Long Acting 1 Mg
• Injection Pegaptanib Sodium 0.3 Mg
• Injection Pegfilgrastim 6 Mg
• Ranibizumab Injection
• Injection Rasburicase 0.5 Mg
• Injection Reslizumab 1Mg
• Inj Sargramostin (Gm-Csf)/50Mcg
• Inj Sebelipase Alfa 1 Mg
• Inj Taliglucerace Alfa 10 U
• Injection Tildrakizumab 1 Mg
• Inj Triptorelin Pamoate 3.75 Mg
• Injection Triptorelin Extended-Release 3.75 Mg
• Inject Vestronidase Alfa-Vjbk 1 Mg
• Injection Voretigene Neparvovec-Rzyl 1 B Vec G
• Hyaluronan/Derivative Durolane For Ia Inj 1 Mg
• Hyaluronan/Derivitive Genvisc 850 Ia Inj 1 Mg
• Hyal Hyalgn Supartz/Vsco-3 Ia Inj-D
• Hyaluronan/Driv Hymovis Ia Inj 1 Mg
• Euflexxa Inj Per Dose
• Synvisc Or Synvisc-One
• Gel-One
• Monovisc Inj Per Dose
• Hyal/Deriv Gelsyn-3 Ia Inj 0.1 Mg
• Hyaluronan/Derivative Trivisc For Ia Inj 1 Mg
• Autol Culturd Chondrocytes Imp
• Hyaluronan/Derivative Synojoynt Ia Inj 1 Mg
• Hyaluronan/Derivative Triluron Ia Inj 1 Mg
• Carbidopa 5 Mg/Levodopa 20 Mg Enteral Suspension, 100 Ml
• Treprostinil Non-Comp Unit
• Injection Azacitidine 1 Mg
• Brentuximab Vedotin Inj
• Inj Cladribine Per 1 Mg
• Degarelix Injection
• Injection Gemcitabine Hcl Nos 200 Mg
• Goserelin Acetate Implant Per 3.6 Mg
• Leuprolide Acetate For Depot Suspension 7.5 Mg
• Vantas Implant
• Supprelin La Implant
• Inj Omacetaxine Mep 0.01Mg
• Pegaspargase Injection
• Injection Pembrolizumab 1 Mg
• Inj Talimogene Laherparepvec
• Injection Trastuzumab 10 Mg And Hyaluronidase-Oysk
• Inj Ziv-Aflibercept 1Mg
• Not Otherwise Classified Antineoplastic Drugs
• Kte-C19 To 200 M A Anti-Cd19 Car Pos T Ce P Td
• Inj Beta Interferon Im 1 Mcg
• Injection, Zarxio
• Injection, Renflexis
• Injection Epoetin Alfa-Epbx Biosimilar 1000 U
• Herzuma Injection
• Inj, Makena
• Immune Globulin Human-Iv Use
• Human Ig Sc
• Botulinum Antitoxin-Equine-Any Route
• Injection Cerliponase Alfa 1 Mg
• Inj Triptorelin Extend Rel 3.75 Mg
• Injection, Elosulfase Alfa
• Injection Vedolizumab 1 Mg
• Unclassified Drugs Or Biologicals
• Injection Pasireotide Long Acting 1 Mg
• Injection, Sebelipase Alfa, 1 Mg
• Injection, Ocrelizumab, 1 Mg
• Injection Epoetin Alfa 1000 Units For Esrd On Dialysis
• Inj Filgrastim 300 Mcg
• Inj Filgrastim 480 Mcg
• Injection Histrelin Acetate 10 Micrograms
• Hydroxyprogesterone Caproate
• Injection Ibalizumab-Uiyk 10 Mg
• Inj Imiglucerase Per Unit
• Injection Interferon Beta-1A 33 Mcg
• Prescription Drug-Oral-Non-Chemotherapeutic-Nos
• Alemtuzumab Injection
• Asparaginase Nos
• Interferon Alfa-2A Inj
• Inj Beta Interferon Sq 1 Mcg
• Injection Infliximab-Qbtx Biosimilar 10 Mg
• Synagis
• Inj Epo 1 Mcg Esrd On Dialysis
• Inj Epoetin Beta 1 Mcg Non-Esrd Use
• Sildenafil Citrate 25 Mg
• Injection Pegylated Interferon Alfa-2A 180 Mcg /Ml
• Peg Interferon Alfa-2B/10
• Unclassified Drugs
• Unclassified Biologics
• Injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg
• Injection, trastuzumab-qyyp, biosimilar, (Trazimera), 10 mg
• Injection, rituximab-pvvr, biosimilar, (Ruxience), 10 mg

• Respiratory Syncytial Virus Immune Globulin
• Lutetium Lu 177 Dotatate Therapeutic 1 Mci
• Abatacept Injection
• Injection Agalsidase Beta 1 Mg
• Injection Alemtuzumab 1 Mg
• Lumizyme Injection
• Alpha 1 Proteinase Inhibitor
• Glassia Injection
• Belimumab Injection
• Injection Cerliponase Alfa 1 Mg
• Injection Lanadelumab-Flyo 1 Mg
• Inj C1 Esterase Inhib Ruconest 10 U
• C-1 Esterase Berinert
• C-1 Esterase Cinryze
• Injection C-1 Esterase Inhibitor 10 Units
• Injection Etelcalcetide 0.1 Mg
• Canakinumab Injection
• Collagenase Clost Hist Inj
• Inj Corticotropin To 40 Units
• Denosumab Injection
• Ecallantide Injection
• Eculizumab Injection
• Injection Edaravone 1 Mg
• Elosulfase Alfa Injection
• Inj Epoprostenol 0.5 Mg
• Inj Ivig Privigen 500 Mg
• Inj Gamma Globulin Im 1 Cc
• Injection Immune Globulin 100 Mg
• Inj Imm Glob Bivigam 500Mg
• Gammaplex Injection
• Hizentra Injection
• Inj Gamma Globulin Im Over 10 Cc
• Gamunex-C/Gammaked
• Immune Globulin Powder
• Octagam Injection
• Gammagard Liquid Injection
• Flebogamma Injection
• Inj Ig/Hyaluronidase 100 Mg Ig
• Ivig Non-Lyophilized Nos
• Golimumab For Iv Use 1Mg
• Idursulfase Injection
• Inj Infliximab Excl Biosimilr 10 Mg
• Imuglucerase Injection
• Injection Laronidase 0.1 Mg
• Injection Mepolizumab 1Mg
• Natalizumab Injection
• Injection Nusinersen 0.1 Mg
• Injection Ocrelizumab 1 Mg
• Injection Omalizumab 5 Mg
• Pegloticase Injection
• Plerixafor Injection
• Romiplostim Injection
• Injection Romosozumab-Aqqg 1 Mg
• Tocilizumab Injection
• Injection Treprostinil 1 Mg
• Ustekinumab Intravenous Inj 1 Mg
• Injection Vedolizumab 1 Mg
• Velaglucerase Alfa
• Injection Emicizumab-Kxwh 0.5 Mg
• Inj Factor X (Human) 1Iu
• Injection Human Fibrinogen Concentrate 1 Mg
• Injection Human Fibrinogen Conc Nos 1 Mg
• Vonvendi Inj 1 Iu Vwf:Rco
• Factor Xiii Anti-Hem Factor
• Factor Xiii Recomb A-Subunit
• Factor Viii Recomb Novoeight
• Wilate Injection
• Xyntha Inj
• Antihemophilic Viii Vwf Comp
• Humate-P Inj
• Injection Factor Viii Per I.U.
• Factor Viia Antihemophilic Factor Recombinant /1 Microgram
• Factor Viii (Anti-Hemophilic Factor Human)Per Iu
• Factor Viii Recombinant Nos
• Factor Ix (Antihemophilic Factor Purified Non-Recombinant) Per I.U.
• Factor Ix Complx Per Iu
• Factor Ix Recombinant Nos
• Antithrombin Iii (Human) Per Iu
• Anti-Inhibitor Per I.U.
• Hemophilia Clotting Factor Noc
• Factor Ix Recombinan Rixubis
• Inj Factor Ix Fc Fus Protein Per Iu
• Factor Ix Idelvion Inj
• Injection Factor Ix Glycopegylated 1 Iu
• Inj Factor Viii Fc Fusion Per Iu
• Factor Viii Pegylated Recomb
• Injection Factor Viii Pegylated-Aucl 1 Iu
• Factor Viii Nuwiq Recomb 1Iu
• Inj Factor Viii Afstyla 1 I.U.
• Inj Factor Viii Kovaltry 1 I.U.
• Orthovisc Inj Per Dose
• Injection Avelumab 10 Mg
• Injection Bevacizumab 10 Mg
• Injection Blinatumomab 1 Microgram
• Injection Copanlisib 1 Mg
• Injection Liposomal 1 Mg Dnr And 2.27 Mg Ca
• Injection Durvalumab 10 Mg
• Inj Gemtuzumab Ozogamicin 0.1 Mg
• Injection Mogamulizumab-Kpkc 1 Mg
• Injection Emapalumab-Lzsg 1 Mg
• Ipilimumab Injection
• Injection Inotuzumab Ozogamicin 0.1 Mg
• Injection Tagraxofusp-Erzs 10 Mcg
• Injection Pertuzumab 1 Mg
• Injection Polatuzumab Vedotin-Piiq 1 Mg
• Injection Rituximab 10 Mg And Hyaluronidase
• Injection Rituximab 10 Mg
• Inj Ado-Trastuzumab Emt 1Mg
• Injection Trastuzumab Excludes Biosimilar 10 Mg
• Tisagenlecleucel To 600 M Car-Pos Vi T Ce Per Td
• Sipleucel-T Auto Cd54+
• Injection, Inflectra
• Injection Bevacizumab-Awwb Biosimilar 10 Mg
• Inj Pegflgrstm-Jmdb Biosimlr 0.5 Mg
• Ogivri (Trastuzumab)
• Truxima Injection
• Kanijnti Injection
• Spl Radophrm Tx Imag Agt Noc
• Injection, Brexanolone, 1Mg
• Kcentra, Per I.U.
• Aflibercept Injection
• Injection Brolucizumab-Dbll 1 Mg
• Alglucosidase Alfa Injection
• Injection Patisiran 0.1 Mg
• Injection Benralizumab 1 Mg
• Injection Bezlotoxumab 10 Mg
• Buprenorphine Implant 74.2Mg
• Injection Burosumab-Twza 1 Mg
• Injection Onabotulinumtoxina
• Abobotulinumtoxina
• Inj Rimabotulinumtoxinb
• Incobotulinumtoxin A
• Certolizumab Pegol Inj 1Mg
• Injection Darbepoetin Alfa 1 Microgram Non-Esrd Use
• Injection Darbepoetin Alfa 1 Microgram For Esrd On Dialysis
• Injection Epoetin Alfa For Non-Esrd Use 1000 Units
• Epoetin Beta Esrd Use
• Epoetin Beta Non Esrd
• Injection Ravulizumab-Cwvz 10 Mg
• Injection Eteplirsen 10 Mg
• Inj Ferric Carboxymaltos 1Mg
• Inj Filgrastim Excl Biosimil
• Injection Tbo-Filgrastim 1 Microg
• Injection Galsulfase 1 Mg
• Injection Glatiramer Acetate 20 Mg
• Injection Hpc 10 Mg
• Injection Hpc Nos 10 Mg
• Interferon Beta-1A Inj
• Interferon Beta-1B Per 0.25 Mg Admin Phys Superv
• Lanreotide Injection
• Inj Leuprolide Acetate Per 3.75 Mg
• Injection Octreotide Depot Form For Intramuscular Injection
• Inj Octreotide Non-Depot Form For Subctns Or Intrvns Inj 25 Mg
• Inj Pasireotide Long Acting 1 Mg
• Injection Pegaptanib Sodium 0.3 Mg
• Injection Pegfilgrastim 6 Mg
• Ranibizumab Injection
• Injection Rasburicase 0.5 Mg
• Injection Reslizumab 1Mg
• Inj Sargramostin (Gm-Csf)/50Mcg
• Inj Sebelipase Alfa 1 Mg
• Inj Taliglucerace Alfa 10 U
• Injection Tildrakizumab 1 Mg
• Inj Triptorelin Pamoate 3.75 Mg
• Injection Triptorelin Extended-Release 3.75 Mg
• Inject Vestronidase Alfa-Vjbk 1 Mg
• Injection Voretigene Neparvovec-Rzyl 1 B Vec G
• Hyaluronan/Derivative Durolane For Ia Inj 1 Mg
• Hyaluronan/Derivitive Genvisc 850 Ia Inj 1 Mg
• Hyal Hyalgn Supartz/Vsco-3 Ia Inj-D
• Hyaluronan/Driv Hymovis Ia Inj 1 Mg
• Euflexxa Inj Per Dose
• Synvisc Or Synvisc-One
• Gel-One
• Monovisc Inj Per Dose
• Hyal/Deriv Gelsyn-3 Ia Inj 0.1 Mg
• Hyaluronan/Derivative Trivisc For Ia Inj 1 Mg
• Autol Culturd Chondrocytes Imp
• Hyaluronan/Derivative Synojoynt Ia Inj 1 Mg
• Hyaluronan/Derivative Triluron Ia Inj 1 Mg
• Carbidopa 5 Mg/Levodopa 20 Mg Enteral Suspension, 100 Ml
• Treprostinil Non-Comp Unit
• Injection Azacitidine 1 Mg
• Brentuximab Vedotin Inj
• Inj Cladribine Per 1 Mg
• Degarelix Injection
• Injection Gemcitabine Hcl Nos 200 Mg
• Goserelin Acetate Implant Per 3.6 Mg
• Leuprolide Acetate For Depot Suspension 7.5 Mg
• Vantas Implant
• Supprelin La Implant
• Inj Omacetaxine Mep 0.01Mg
• Pegaspargase Injection
• Injection Pembrolizumab 1 Mg
• Inj Talimogene Laherparepvec
• Injection Trastuzumab 10 Mg And Hyaluronidase-Oysk
• Inj Ziv-Aflibercept 1Mg
• Not Otherwise Classified Antineoplastic Drugs
• Kte-C19 To 200 M A Anti-Cd19 Car Pos T Ce P Td
• Inj Beta Interferon Im 1 Mcg
• Injection, Zarxio
• Injection, Renflexis
• Injection Epoetin Alfa-Epbx Biosimilar 1000 U
• Herzuma Injection
• Inj, Makena
• Injection Ibandronate Sodium 1 Mg
• Injection Atezolizumab 10 Mg
• Cabazitaxel Injection
• Injection Daratumumab 10 Mg
• Injection Nivolumab 1 Mg
• Injection Elotuzumab 1Mg

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Medicare Advantage Forms (PDF)
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• Abilify Mycite (aripiprazole tables with sensor)
• Aciphex Sprinkle (rabeprazole sodium)
• Actemra Sub Q (tocilzumab)
• Actiq (fentanyl )
• Actonel (risedronate)
• Actoplus Met/ XR (pioglitazone hcl and metformin hcl)
• Actos (pioglitazone hydrochloride)
• Adcirca (tadalafil)
• Adderall XR (dextroamphetamine)
• Addyi (fibanserin)
• Adempas (Riociguat)
• Admelog/ Solostar (insulin lispro)
• Advair (fluticasone propionate)
• Advair Diskus (fluticasone propionate)
• Advair HFA (fluticasone propionate and salmeterol)
• Aerospan (flunisolide)
• Airduo Respiclick (fluticasone-propionate and salmeterol)
• Aklief (trifarotene)
• Alcortin A (hydrocortisone-lodoquil)
• Aliqopa (copanlisib)
• Allzital (butalbital and acetaminophen)
• Aloqin (uidiqyuhnik/aloe)
• Alsuma (sumatriptain injections)
• Alunbrig (brigatinib)
• Amzeeq (minocycline)
• Androderm (testosterone transdermal system)
• Anzemet (dolasetron)
• Apidra (insulin glulisine [rDNAoring])
• Arcalyst (rilonacept)
• Aricept (donepezil hydrochloride)
• Arikayce (amikacin inhalation soln)
• Arixtra (fondaparinux sodium)
• Arnuity Ellipta (fluticasone furoate inhalation powder)
• Asacol HD (mesalazine)
• Atralin (tretinoin)
• Aubagio (Teriflunomide)
• Austedo (deutetrabenazine)
• Avandamet (rosiglitazone maleate and metformin)
• Avandaryl (rosiglitazone maleate and glimepiride)
• Avandia (rosiglitazone maleate)
• Aveed (testosterone undecanoate)
• Avinza (morphine sulfate extended-release capsules)
• Avita (trentinoin)
• Axiron (testosterone topical solution)
• Balversa (erdafitinib)
• Beconase AQ (beclomethasone dipropionate)
• Benlysta (belimumab)
• Binosto (alendronate sodium)
• Braftovi (encorafenib)
• Brand Angiotensin Receptor Blockers (Generic Angiotensin Receptor Blockers )
• Brand Anti-Depressants (Generic Anti-Depressants)
• Brand Antifungal Medications (Generic Antifungal Medications)
• Brand Calcium Channel Blockers (Generic Calcium Channel Blockers )
• Brand Cholesterol Lowering Medications (Generic Cholesterol Lowering Medications)
• Brand Colchicine (Generic colchicine)
• Brand Doxycycline (Generic Doxycycline)
• Brand Ephinephrine Auto-Injector (Generic epinephrine injection, USP)
• Brand Fenofibrates (Generic Fenofibrates)
• Brand nasal steroids (Generic nasal steroids)
• Brand Ophthalmic anti-allergic (Generic Ophthalmic anti-allergic)
• Brand Opioids (Generic Opioids)
• Brand overactive bladder meds (Generic overactive bladder meds)
• Brand Proton Pump Inhibitors (Generic Proton Pump Inhibitors)
• Brand sedative hypnotics (generic sedative hypnotics)
• Brand Topical Acne Products (Generic Topical Acne Products)
• Brand Topical Corticosteroids (Generic Topical Corticosteroids)
• Brand Topical Immunomodulators (Generic Topical Immunomodulators)
• Brand Topical Testosterone (Generic Topical Testosterone)
• Brand Topical Tretinoin (Generic Topical Tretinoin )
• Brand Triptans (generic triptans)
• Breo Ellipta (fluticasone furoate and vilanterol)
• Bruskinsa (zanubrutinib)
• Bryhal (halobetasol propionate lotion)
• Buprenex (buprenorphine)
• Calcitonin Gene-Related Peptide (CGRP Receptor Antagonists)
• Calquence (acalabrutinib)
• Carbaglu (carglumic acid)
• Cequa (cyclosporine ophthalmic solution)
• Chenodal (chenodiol)
• Chorionic Gonadotropin (HGC)
• Cimzia for Crohn's Disease (certolizumbegol for Crohn's Disease)
• Cimzia for Rheumatoid Arthritis (certolizumbegol for Rheumatoid Arthritis)
• Climara Pro (Estradiol, Levonorgestrel Transermal)
• Compounded Medications (Compounded Medications)
• Consensi (amlodipine and celecoxib)
• Continuous Glucose Monitors (Continuous Glucose Monitors)
• Copaxone (Glatiramer Acetate )
• Coremino (minocycline)
• Cosentyx for Psoriasis (Cosentyx for Psoriasis)
• Cosentyx (secukinumab)
• Crohn's Disease (Biologic Therapies)
• Cystagon (cysteamie bitartrate)
• Cystaran (systeamie ophthalmic solution)
• Daklinza (daclatasvir)
• Daliresp (roflumilast)
• Daraprim (pyrimethamine)
• Daurismo (glasdegib)
• Daytrana (methylphenidate)
• Delatestryl (testosterone enanthate)
• Delzicol (mesalazine)
• Depakote/ER/sprinkle capsule (divalproex sodium)
• Depo-Testosterone (Depo-Testosterone)
• Dexcom (continuous glucose monitor)
• Dexpak (dexamethasone)
• Diacomit (Stiripentol)
• Diclo Gel (diclofenac gel)
• Diclofono (diclosenac sodium)
• Didanosine (Didanosine)
• Dipentum (olsalazine sodium)
• Diskets Dispersible Tablets (methadone tablets for oral suspension)
• Doptelet (avatrombopag)
• Duaklir (aclidinium bromide/formoterol fumarate)
• Dulera (mometasone furoate/formoterol fumarateddihydrate)
• Dupixent (dupilumab)
• Durlaza (aspirin)
• Egrifta (tesamorelin)
• Eliquis (apixaban)
• Emend (aprepitant)
• Emflaza (deflazacor)
• Enbrel for Psoriasis (etanercept for Psoriasis)
• Enbrel for Rheumatoid Arthritis (etanercept for Rheumatoid Arthritis)
• Endari (L-glutamine oral powder)
• Endometrin (progesterone)
• Epclusa (sofosbuvir-velpatasvir)
• Epiduo (Adapalene-Benzoyl Peroxide )
• Erleada (apalutamide)
• Esbriet (pirfenidone)
• Estrogel (estradiol gel)
• Evarsus XR (tacrolimus extended release capsules)
• Evista (Raloxifene )
• Extavia (interferon beta-1b)
• Fabior (tazarotene)
• Femring (estradiol acetate)
• Femtrace (estradiol)
• Fetzima (levomilnacipran er)
• Firazyr (icatibant)
• Firdapse (Amifampridine)
• Flolan (epoprostenol sodium)
• Florouracil 0.5% Cream (florouracil topical)
• Flowtuss (hydrocodone bitartrate and guaifenesin)
• Fortamet ER (metformin ER)
• Forteo (teriparatide)
• Galafold (migalastat)
• General PA Form for exception requests (General PA Form for exception requests)
• Gileyna (Gileyna)
• Glumetza XR (metformin ER)
• Gocovri (amantadine extended release)
• Harvoni (ledipasvir/sofosbuvir)
• Hetlioz (tasimelteon)
• Humira for Crohn's Disease (adalimumab for Crohn's Disease)
• Humira for Psoriasis (adalimumab )
• Humira for Rheumatoid Arthritis (adalimumab for Rheumatoid Arthritis)
• Hycofenix (hydrocodone bitartrate, pseudoephedrine, hydrochloride and guaifensin oral solution)
• Idhifa (enasidenib)
• Increlex (mecasermin)
• Inderal LA (propranolol)
• Inderide (propranolol hydrochloride and hydrochlorothiazide)
• Indocin (Indomethacin)
• Ingrezza (Valbenzaine)
• InnoPran XL (propranolol hydrochloride)
• Jatenzo (testosterone undecanoate)
• Juxtapid (lomitapide)
• Jynarque (tolvaptan)
• Kalydeco (lvacaftor)
• Keveyis (dichlorphenamide)
• Kevzara (sarilumab)
• Kineret (anakinra)
• Kisqali (Ribociclib)
• Kisqali/Femara (Ribociclib/Letrozole)
• Korlym (mifepristone)
• Kuvan (sapropterin)
• Kynamro (mipomersen sodium)
• Kytril (granisetron)
• Letairis (ambrisentan)
• Lexixryl (diclofenac sodium)
• Lidoderm (lidocaine patch)
• Lillow (levonorgestrel-ethinyl estrad)
• Lorbrena (lorlatinib)
• Lovaza (omega-3-acid ethyl esters)
• Lumigan (bimatoprost ophthalmic solution)
• Lupron Depot-Ped (Leuprolide Acetate Injection)
• Mavenclad (cladribine)
• Mavyret (glecaprevir-pibrentasvir)
• Mayzent (siponimod)
• Melodetta 24 FE (norethindrone acetate and ethinyl estradion and ferrous fumarate)
• Mezparox-HC (hydrocortisone-pramoxine)
• Mirvaso (brimonidine gel 0.33%)
• MS-contin (morphine sulfate extended release)
• Mulpleta (lusutrombopag)
• Myalept (metreleptin)
• Mydayis (mixed salts of a single-entity amphetamine product)
• Nalfon (Fenoprofen Capsule )
• Namenda XR (Memantine Hydrochloride ER)
• Natpara (parathyroid hormone)
• Nerlynx (neratinib)
• Neupro Patch (Rotigotine Transdermal System)
• Niravam (alprazolam)
• Non-Preferred Growth Hormone Medications (Preferred Growth Hormone Medications)
• Non-Preferred Hepatitis C Medications (Preferred Hepatitis C Medications)
• Non-Preferred teststrips (Preferred Teststrips)
• Non-Preferred Venlafaxine HCI (Preferred Venlafaxine HCI)
• Norgesic Forte (Orphenadrine Compound Forte )
• Northera (droxidopa)
• Nourianz (istradefylline)
• Novacort (hydrocortisone/pramoxine w/aloe)
• Novolin (insulin isophane)
• Novolog (insulin aspart)
• Nucala (mepolizumab)
• Nudroxipak (celecoxib, methyl salicylate, menthol, capsaicin)
• Nutropin AQ (somatropin)
• Obredon (hydrocodone bitartrate, and guaifensin oral solution)
• Ocaliva (obeticholic acid)
• Ofev (nintedanib)
• Oleptro ER (trazodone-hydrochloride extended release)
• Olumiant (baricitinub)
• Omeppi (omeprazole-sodium bicarbonate)
• Omnitrope (somatropin)
• Onsolis (fentanyl buccal soluble film)
• Opsumit (Macitentan)
• Orenitram ER (treprostinil)
• Orkambi (lumacaftor/ivacaftor)
• Orlissa (elagolix)
• Otezlafor Psoriasis (apremilast for Psoriasis)
• Otezlafor Rheumatoid Arthritis (Otezla for Rheumatoid Arthritis)
• Oxbyrta (voxelotor)
• Oxervate (cenegermine-bkbj)
• Palynzig (pegvaliase-pqpz)
• Pancreaze (pancrelipase)
• Pegylated Interferons (Pegylated Interferons)
• Piqray (alpelisib)
• Plaquenil (hydroxychloroquine)
• Pliaglis (Lidocaine-Tetracaine)
• Plixda (adapalene)
• Pradaxa (dabigatran etexilate)
• Praluent (alirocumab)
• Pregnyl (Chorionic Gonadotropin For Injection)
• Prevacid Solutab (lansoprazole)
• Prilosec Suspension (omeprazole)
• Procysbi (cysteamine bitartrate)
• Promacta (eltrombopag)
• Protonix Suspension (pantoprazole sodium)
• Proventil HFA (albuterol sulfate)
• Provigil/Nuvigil (modafinil/armodafinil)
• Psoriasis Therapies (Biologic Therapies)
• Qbrexza (glycopyrronium cloth 2.4%)
• Quinja (iodoquinol with aloe)
• Rayos (prednisone)
• Refissa (tretinoin emollient)
• Regranex (becaplermin)
• Relpax (eletiptan HBr)
• Repatha (evolocumab)
• Rescula (unoprostone isopropyl)
• Restasis (cyclosporine opthalmic)
• Retin-A/ Micro (tretinoin)
• Revatio (sildenafil citrate)
• Rheumatoid Arthritis Therapies (Biologic Therapies)
• Rhofade (oxymetazoline hydrochloride cream 1%)
• Ribapak (ribavirin)
• Ribasphere (ribavirin)
• Ribatab (ribavirin)
• Rinvoq (upadacitinib)
• Rubraca (rucaparib camsylate)
• Ruzurgi (amifampridine)
• Rydapt (midostaurin)
• Sabril (vigabatrin)
• Saizen (somatropin)
• Samsca (tolvaptan)
• Sandostatin Lar Depot (octreotide acetate injection)
• Savaysa (Edoxaban)
• Savella (milnacipran HC)
• Selzentry (maraviroc)
• Seroquel XR (quetiapine fumarate extended release)
• Seroquel (quetiapine fumarate)
• Signifor Lar (pasireotide)
• Siliq (brodalumab)
• Simponifor Crohn's Disease (golimumab for Crohn's Disease)
• Simponifor Rheumatoid Arthritis (golimumab for Rheumatoid Arthritis)
• Skyrizi (Skyrizi)
• Solaraze (diclofenac sodium)
• Sovaldi (sofosbuvir)
• Spiriva (tiotropium brominde)
• Spravato (Esketamine)
• Stelara Sub-Q (ustekinumab)
• Strensiq (asfotase alfa)
• Subsys (fentanyl sublingual spray)
• Sumavel Dosepro (sumatriptain)
• Sunsosi (budesonide/formoterol fumarate dihydrate)
• Sustiva (Efavirenz )
• Symbicort (budesonide/formoterol fumarate dihydrate)
• Symdeko (tezacaftor/ivacaftor)
• Symlin (pramlintide acetate)
• Symtouch (sumatriptain injections)
• Syprine, Clovique, Trientine (Chelating Agents)
• Takhzyro (lanadeumab-flyo)
• Taltz (Taltz)
• Talzenna (talazoparib)
• Tanzeum (albiglutide)
• Tavalisse (fostamatinib disodium hexahydrate)
• Tazorac (tazarotene gel)
• Tegsedi (inotersen)
• Testim (Testosterone Gel )
• Tibsovo (ivosidenib)
• Timoptic Ocudose (timolol maleate ophthalmic solution)
• Topamax (toprimate)
• Tracleer (bosentan)
• Travatan Z (travoprost ophthalmic solution)
• Travoprost 0.0004% opthalmic solution (Travoprost 0.0004% opthalmic solution)
• Tremfya (guselkumab)
• Tretin-X (trentinoin)
• Trikafta (elexacaftor/tezacaftor/ivacaftor)
• Trintellix (vortioxetine)
• Trokendi XR (toprimate)
• Trulance (plecanatide)
• Trulicity (dulaglutide)
• Tussicaps (hydrocodone, chlorpheniramine)
• Tuzistra XR (codeine polistirex and chlorpheniramine polistirex)
• Tymlos (abaloparatide)
• Ultram ER (tramadol hydrochloride extended-release tablets)
• Ultresa (pancrelipase)
• Uptravi (selexipag)
• Vanatol LQ (butalbital, acetamionophen and caffeine)
• Vanatol S (butalbital, acetaminophen and caffeine)
• Vascepa (icosapent ethyl)
• Ventavis (iloprost)
• Veramyst (fluticasone furoate)
• Verzenio (abemaciclib)
• Victoza (liraglutide)
• Vigadrone (Vigabatrin)
• Viibryd (vilazodone)
• Vitrakvi (larotrectinib)
• Vituz (hydrocodone bitartrate and chlorpheniramine malaete)
• Vizimpro (Dacomitinib)
• Vosevi (sofosbuvir/velpatasvir/voxilaprevir)
• Vyleesi (bremelanotide)
• Vyndaqel (tafamidis meglumie)
• Vyndamax (tafamidis)
• Vyvanse (lisdexamfetamine)
• Wakix (pitolisant)
• Xalatan (latanoprost)
• Xalkori (crizotinib)
• Xarelto 15 mg and 20 mg only (rivaroxaban)
• Xatmep (methotrexate oral solution)
• Xeljanz (tofacitinib citrate)
• Xepi (ozenoxacin)
• Xermelo (Telotristat)
• Xerses Cream (Acyclovir And Hydrocortisone)
• Xospata (gilteritinib)
• Xpovio (selinexor)
• Xsail (sumatriptain nasal powder)
• Xyosted (testosterone enanthate)
• Xyrem (sodium oxybate)
• Yasmin (Drospirenone)
• Yonsa (abiraterone acetate)
• Zebeta (bisoprolol fumarate)
• Zecuity (sumatriptain iontophoretic transdermal system)
• Zejula (Niraparib)
• Zema-Pak (dexamethasone)
• Zepatier (elbasvir & grazoprevir)
• Zerviate (cetirizine ophthalmic solution)
• Ziana (clindamycin phosphate and trentioin)
• Zioptan (tafluprost)
• Zodex (dexamethasone)
• Zofran (ondansetron for Anti-Nausea)
• Zomacton (somatropin)
• Zomig (zolmitriptan)
• Zonacort (dexamethasone)
• Zonegran (zonisamide)
• Zorbtive (somatropin)
• Zubsolv (buprenorphihne & naloxone)
• Zurampic (Lesinurad)
• Ibrance (palbociclib)
• Nexletol (bempedoic acid)
• Nurtec(rimegepant)
• Trijardy XR(empagliflozin/linagliptin/metformin HCI)
• Nicardipine Hydrochloride (Cardene)
• Vanadom(carisoprodol)
• Atropie sulfate monohydrate(isopto Atropine)
• Seebri Nechaler(glycopyrrolate)
• Tudorza Pressair(aclidinium, bromide)
• Ala -Scalp(hydrocortisone)
• Triptodur(triptorelin)
• Absorica (isotretinoin)
• Airduo (fluticasone/salmeterol)
• Ajovy (fremanezumab)
• Arymo ER (morphine)
• Colcrys (colchicine)
• Duaklir (aclidinium/formoterol)
• Dulera (mometasone/formoterol)
• Hydrocodone ER (hydrocodone)
• Incruse (umeclidinium)
• Invokana (canagliflozin)
• Invokamet (canagliflozin)
• Invokamet ER (canagliflozin/metformin)
• Kadian (morphine)
• Mitigare (colchicine)
• Nucynta ER (tapentadol)
• Seebri (glycopyrrolate)
• Segluromet (ertugliflozin/metformin)
• Steglatro (ertugliflozin)
• Tudorza (aclidinium)
• Utibron (indacaterol/glycopyrrolate)
• Zohydro ER (hydrocodone)

View the list of medications that may require prior authorization. You will leave the Blue KC Provider Portal as you continue.

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Commercial Plan Members (and Small Group ACA Members)
Pharmacy Benefit Rx (PromptPA)

ACA and Medicare Advantage Plan Members
Pharmacy Benefit Rx (OptumPAS)

The member ID for someone in an ACA Individual Family Plan will begin with one of the following prefixes:
YBD, YBS, YBM, YBT, YBX, YJV, YJW, YJJ or YJT.

The member ID for a Medicare Advantage member will begin with a prefix of RRK or RKN.