Prior Authorization Form
Out-of-State Pre-Notification Form
Medical Management Satisfaction Survey
Episode Management Portal (AuthAuth)
List of Services requiring Prior Authorization
Services That Must be Pre-certified by the Innovation Care Partners: Medical Management Department:
- All hospital admissions, except Observation Room > 24 hours stays (Observation Stays greater than 72 hours must be authorized by ICP)
- All hospital admissions for pregnant woman when there is a hospital stay that lasts longer than 48 hours (following a normal vaginal delivery) or 96 hours (following a cesarean section)
- All elective surgical procedures to be performed in a hospital-based or free-standing outpatient ambulatory surgical facility (note: Ophthalmology authorizations will be for surgical procedure only not place of service) Except Colonoscopies
- [Potentially] Cosmetic Procedures (ex: Breast Reduction & Reconstruction, Blepharoplasty, Strabismus)
- Durable Medical Equipment (DME) purchases over $1,000
- Prosthetics and orthotics over $2,000
- Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computed Tomography Angiography (CTA) and Positron Emission Tomography (PET) scans
- Pain Management services (examples: epidurals or implantable infusion pumps)
- Surgical treatment of TMJ conditions
- Home health care (including HonorHealth Home Care)
- Home infusion therapy services
- Specialty infusion/injectable medications which are covered under the Medical Benefit and not obtained through the Prescription Drug Benefit – please refer to ICP’s 2024 Medical Benefit Prescription Medication Prior Authorization Listing below
- Transplants: bone marrow, stem cell, heart, intestine, kidney, liver, lung, pancreas.
- Experimental or Investigational treatments or surgeries (including Clinical Trials)
- Genetic Testing Lab Fees (All genetics testing must have 3rd party pre-test counseling documentation to obtain prior authorization for labs.)
- Services at any post-acute facility (SNF, AIR, LTAC, etc.)
- Ambulance Services (non-emergent)
- Hyperbaric Oxygen Therapy
- Ventricular Assistive Device (VAD); Life Vests; Implantable Cardiac Defibrillators
- Proton Beam Therapy
- Speech Therapy
- Adoptive Cell Therapy
- Testosterone Hormone Therapy for Males
- Outpatient Dialysis
- Psychological testing & neuropsychologic testing (if submitting a claim to the medical benefit plan)
Mental Health and Substance Abuse Services That Must be Pre-certified by Magellan Health:
- Inpatient hospitalization (IP)
- Residential hospitalization (RES)
- Intensive outpatient (IOP)
- Partial hospitalization (PHP)
- Electroconvulsive therapy (ECT)
- Transcranial magnetic stimulation (TMS)
- Psychological testing
- Neuropsychological testing
- Biofeedback
- Applied behavioral analysis (ABA) therapy
Note: Pre-certification is not required for routine outpatient services.
Magellan Behavioral Health Pre-Certification Telephone Number is (800) 424-4138.
Specialty infusion/injectable medications which are covered under the Medical Benefits and not obtained through the Prescription Drug Benefits.
The following drugs require prior authorization:
- Anticonvulsant: vigabatrin (Sabil®)
- Botulinum toxin type A and B: Botox®, Dysport®, Jeuveau®, Myobloc®, and Xeomin®
- Cystic Fibrosis agent: elexacaftor/tezacaftor/ivacaftor (Trikafta®)
- C1 Inhibitors: Cinryze®, Haegarda® and Berinert®
- Blood cell deficiency/erythropoiesis stimulating agents (ESA): Epoetin (Epogen®, Procrit®, Retacrit®), Darbepoetin (Aranesp®), Methoxy polyethylene glycol-epoetin beta (Mircera®), and Oprelvekin (Neumega®)
- Growth hormones:
- Somatropin (Genotropin®, Humatrope®, Norditropin FlexPro®, Nutropin AQ NuSpin®, Omnitrope®, Saizen®, Saizenprep®, Serostim®, Zomacton®, and Zorbtive®)
- Tesamorelin (Egrifta SV®)
- Macimorelin (Macrilen®)
- Lonapegsomatropin (Skytrofa®)
- Somapacitan (Sogroya®)
- Growth hormone blocker: Mecasermin (Increlex®)
- HIV agent: bictegravir/emtricitabine/tenofovir (Biktavy®)
- Immunologic agents/immune modulators/biologics/monoclonal antibody agents: Abatacept (Orencia®)®) *dalimumab (Humira®), Anakinra (Kineret®), Belimumab (Benlysta®), Certolizumab (Cimzia®), Etanercept (Enbrel®), Eculizumab (Soliris®), Fingolimod (Gilenya®), Glatiramer Acetate (Copaxone®, Glatopa®), Golimumab (Simponi®), Infliximab (Remicade®), Secukinumab (Cosentyx®), Tofacitinib (Actemra®), Rituximab (Rituxan®)*, Ustekinumab (Stelara®), and Vedolizumab (Entyvio®), infliximab axxq (Avsola®), infliximab-dyyb (Inflectra®), infliximab-abda (Renflexis®) *except for chemotherapy
- Immunoglobulins:
- Intravenous: Asceniv, Bivigam, Flebogamma DIF, Gammaked, Gammaplex, Gamunex-C, Octagam, Panzyga, and Privigen
- Subcutaneous: Cutaquig, Cuvitru, Gammagard S/D Liquid, Gammaked, Gamunex-C, Hizentra, Hyqvia, and Xembify
- Intramuscular: GamaSTAN
- Bone condition agents: Denosumab (Prolia®, Xgeva®), and Zoledronic Acid (Reclast®)
- Respiratory conditions: Reslizumab (Cinqair®), Dupilumab (Dupixent®), Benralizumab (Fasenra®), Mepolizumab (Nucala®), Tezepelumab (Tezspire®), and Omalizumab (Xolair®)
- Eye conditions: Aflibercept (Eylea®) and Ranibizumab (Lucentis®)
- Enzyme deficiency: Agalsidase Beta (Fabrazyme®) and Pegloticase (Krystexxa®)
- Endocrine disorders: Octreotide (Sandostatin®), Lanreotide (Somatuline Depot®), and Pasireotide (Signifor LAR®)
- Gene Therapy: idecabtagene vicleucel (Abecma®), lisocabtagene maraleucel (Breyanzi®), ciltacabtagene autoleucel (Carvykti®), tisagenlecleuce (Kymriah®), voretigene neparvovec-rzyl (Luxturna®), talimogene laherparepvec (Imlygic®), brexucabtagene autoleucel (Tecartus®), axicabtagene (Yescarta®), onasemnogene abeparvovec (Zolgensma®), exagamglogene autotemcel (Casgevy®), lovotibeglogene autotemcel (Lyfgenia®)
- Alzheimer’s disease: Aducanumab-avwa (Aduhelm®)
- Protein C deficiency: Protein C, Human (Ceprotin®)
- Miscellaneous specialty medications: Nusinersen (Spinraza®), Eteplirsen (Exondys 51®), Cerliponase alfa (Brineura®), Enteral Formula and Parenteral Nutrition, Ravulizumab-cwvz (Ultomiris®), efgartigimod alfa-fcab (Vyvgart®)
Medical Management Required 340-B Prior Authorization Specialty Medication Listing*:
- Copaxone
- Cosentyx
- Enbrel
- Gilenya
- Humira
- Hyqvia
- Norditropin
- Omnitrope
- Simponi
- Stelara
- Xolair
*The medications on the "Medical Management Required 340-B Prior Authorization Specialty Medication Listing" require prior authorization requests be submitted to ICP Prior Authorization Department AND HonorHealth Specialty Medication program, telephone #602-674-6222.
ICP Clinical Criteria and Guidelines
ICP makes Utilization Management (UM) decisions based only on appropriateness of care and service, including existence of coverage.
The ICP UM Department uses clinically sound, nationally developed and accepted criteria for making medical necessity decisions.
Below is the list of the clinical criteria used, but is not limited to:
Milliman Care Guidelines
UpToDate
Choosing Wisely
Micromedex
Government agencies such as US Food & Drug(FDA), Centers for Medicare and Medicaid(CMS), Centers for Disease Control and Prevention(CDC), PubMed
Clinical practice guidelines by National Associations when available
Innovation Care Partner’s Physician developed evidence-based guidelines
ICP uses nationally recognized clinical criteria to make evidence-based UM decisions. Criteria is available upon request by contacting (480) 400-0027.
Denials & Appeals
Following a request for service, you may receive notification of denial of service. Services can be denied related to your current health plan benefits and coverage, for not meeting medical necessity criteria, or for a service that is excluded from coverage under the provision of your plan.
Innovation Care Partners Medical Management Department discuss the necessary information related to the denial of services and advise you regarding the process should you wish to appeal this decision.
If you have received a notice of denial and you have questions or want to appeal the decision, please call:
Innovation Care Partners Medical Management Department
Phone: 1-800-250-6647
Fax: 480-588-8061
Toll Free Fax: 1-833-665-1252
Medical Management Directory
Webpage: www.icppatient.com or www.icppatient.com/priorauth
Phone numbers:
- 1-800-250-6647
- 480-400-0027
E-Mail:
Fax Number:
- 480-588-8061
- Toll free 1-833-665-1252
Out of Area and Facility Admission Notification:
- 1-800-250-6647
- Or fax to 1-833-665-1252
Utilization Review Nurse
Local Voice Mail: 480-681-6502
Out of Area: 1-800-250-6991
E-mail: [email protected]