PA Lookup

If you have questions about prior authorizations, please call:

Member and Recipient Service Line: 1-877-685-2415

Provider Support Service Line: 1-855-250-1539

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12437 Results

Amikacin

Service Code
80150 (CPT) Amikacin
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Amiodarone

Service Code
80151 (CPT) Amiodarone
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Caffeine

Service Code
80155 (CPT) Caffeine
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Carbamazepine; total

Service Code
80156 (CPT) Carbamazepine; total
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Carbamazepine; free

Service Code
80157 (CPT) Carbamazepine; free
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Cyclosporine

Service Code
80158 (CPT) Cyclosporine
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Clozapine

Service Code
80159 (CPT) Clozapine
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Digoxin; total

Service Code
80162 (CPT) Digoxin; total
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Digoxin; free

Service Code
80163 (CPT) Digoxin; free
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Valproic acid (dipropylacetic acid); total

Service Code
80164 (CPT) Valproic acid (dipropylacetic acid); total
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Valproic acid (dipropylacetic acid); free

Service Code
80165 (CPT) Valproic acid (dipropylacetic acid); free
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Felbamate

Service Code
80167 (CPT) Felbamate
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Ethosuximide

Service Code
80168 (CPT) Ethosuximide
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Everolimus

Service Code
80169 (CPT) Everolimus
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Gentamicin

Service Code
80170 (CPT) Gentamicin
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Gabapentin, whole blood, serum, or plasma

Service Code
80171 (CPT) Gabapentin, whole blood, serum, or plasma
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Haloperidol

Service Code
80173 (CPT) Haloperidol
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Lamotrigine

Service Code
80175 (CPT) Lamotrigine
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Lidocaine

Service Code
80176 (CPT) Lidocaine
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Levetiracetam

Service Code
80177 (CPT) Levetiracetam
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required