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.