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Medicare Advantage

The services listed here require prior authorization for all Individual and Group Medicare Advantage plans.

Note: PPO plans do not require prior authorization for out-of-network services. Group POS plans require prior authorization for both in-and out-of-network services.

Services Requiring Prior Authorization

  • All Inpatient Admissions (excluding maternity admissions)
  • All elective acute care admissions (excluding maternity admissions) including:
    • Elective Surgical admissions
    • Elective Medical admissions
    • All rehabilitation facility admissions (e.g., Acute Rehab, Skilled Nursing Facility (SNF) and Sub-Acute admissions)
    • Mental health , substance abuse admissions, or partial hospitalizations (Prior authorization is performed by Horizon Behavioral Health)
  • Ambulance transportation (non-emergent only) - Ground or Air
  • Bariatric Procedures (for example: Gastric Bypass)
  • Breast Reconstruction
  • Cardiac Radiology Services (Non emergent only) (Prior authorization performed by eviCore healthcare)
  • Diagnostic Cardiac Catheterization / Echo Stress (Non-emergent only) (Prior authorization performed by eviCore healthcare)
  • Cosmetic Procedures - any potentially cosmetic procedure including cosmetic dermatology services; Examples:
    • Breast Reconstruction / Reduction Mammoplasty
    • Bone Graft
    • Excision of Excessive Skin - Lipectomy
    • Gynecomastia - surgical treatment
    • Orthognathic Surgery
    • Osteotomies
    • Rhinoplasty/Rhytidectomy/Septoplasty/Sinus Surgery
    • Sclerotherapy or Surgery for Varicose Veins
    • Cosmetic Eyelid surgery (e.g., Blepharoplasty/Canthoplasty)
    • Pectus excavatum repair
  • Diabetic Supplies and Services
  • Durable Medical Equipment (DME) and Prosthetics
  • Eyelid Surgery
  • Home Health Care Services (All skilled services provided in the home)
  • Home Infusion Services
  • Home Telemonitoring
  • Hyperbaric Oxygen Treatment
  • Laboratory services that cannot be provided by participating freestanding laboratories
  • Mental Health services
  • Occupational Therapy
  • Orthognathic Jaw Surgery
  • Out-of-network requests for consideration of In-Network level of benefit when a network deficiency exists
  • Pain Management Injections (Prior authorization performed by eviCore healthcare)
  • Physical Therapy
  • Radiology services (Prior authorization performed by eviCore healthcare)
    • CT/CTA Scans
    • MRI/MRA
    • Nuclear Medicine/Nuclear Cardiology
    • PET and PET/CT Scans
  • Sinus and Nasal Surgery
  • Surgery for Sleep Apnea (e.g., Uvelopalatopharyngoplasty [UPPP]/uvelopalatoplasty [UPP])
  • Specialty Pharmaceuticals/Drugs (e.g., Botox, IVIG, Flolan and derivates; Xolair)>
  • Speech Therapy
  • Temporomandibular Joint Surgery and Jaw Surgery
  • Transgender Surgery
  • Transplant Services/Organ Transplants (excluding Corneal Transplants)


Please note that, in addition to the above-listed services, members enrolled in the Horizon NJ TotalCare (HMO SNP) plan must also obtain Prior Authorization for the services listed below.

  • Cardiac Rehabilitation
  • Chiropractic Services
  • Dental Services (as indicated below):
    • Crowns and crown build ups (once per 5 years)
    • Dentures and periodontics
    • Orthodontics for members under the 18 years of age where medical necessity is established and/or to correct a facial abnormality
    • Prosthodontics
    • Bridgework
    • Oral Surgery
    • Root Canals
    • Sedation
  • Durable Medical Equipment and Prosthetics (above $250), Orthotics (above $500)
  • Hearing aids
  • Hospice services (palliative and curative care) for members under age 21 years
  • Hysterectomy
  • Incontinent supplies (Medline vendor authorization required for monthly count >180 ct)
  • Medical Day Care health services (Adult and Pediatric)
  • Nursing Facility Care (custodial care)
  • Nutritional supplements and foods associated with genetic disorders or inborn errors of metabolism and treatment of weight loss due a medical condition
  • Personal Care Assistant Services (PCA)
  • Private duty nursing services provided to all eligible members under age 21 years
  • Pulmonary Rehabilitation
  • Sterilization
  • MLTSS (Managed Long Term Services & Supports) services