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Download the latest precertification requirement list

December 30, 2014

For the most up-to-date list of services and specialty drugs that require precertification, download the latest version of the Preapproval/Precertification List.

As a reminder, significant changes go into effect January 1, 2015, for the following three categories:

  • Non-emergent outpatient radiation therapy. Precertification through CareCore National, LLC, an independent company, is required for non-emergent outpatient radiation therapy for all commercial and Medicare Advantage HMO and PPO members.
    Note: This precertification requirement does not apply to Federal Employee Program or Comprehensive Major Medical members.
  • Durable medical equipment (DME). DME providers are required to obtain precertification for all APAP, BPAP, and CPAP machines and replacement supplies (e.g., tubing, water chambers, face masks) for all commercial and Medicare Advantage HMO and PPO members.
  • Medical benefit drugs. Precertification approval has been added for BeleodaqTM, EntyvioTM, Keytruda® , Opdivo®, Ruconest®, and SylvantTM. Precertification is no longer required for Aredia®, Arzerra®, Boniva® injection, Ceredase®, Eloxatin®, Nulojix®, Orthovisc®, Synvisc®, and Synvisc-One®.

If you have any questions, please contact Cheryl McGurk, Manager of Precertification, at 215-241-4542.


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