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
12437 Results
Antidepressants, serotonergic class; 6 or more
Service Code
80334 (CPT) Antidepressants, serotonergic class; 6 or more
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Antidepressants, tricyclic and other cyclicals; 1 or 2
Service Code
80335 (CPT) Antidepressants, tricyclic and other cyclicals; 1 or 2
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Antidepressants, tricyclic and other cyclicals; 3-5
Service Code
80336 (CPT) Antidepressants, tricyclic and other cyclicals; 3-5
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Antidepressants, tricyclic and other cyclicals; 6 or more
Service Code
80337 (CPT) Antidepressants, tricyclic and other cyclicals; 6 or more
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Antidepressants, not otherwise specified
Service Code
80338 (CPT) Antidepressants, not otherwise specified
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Antiepileptics, not otherwise specified; 1-3
Service Code
80339 (CPT) Antiepileptics, not otherwise specified; 1-3
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Antiepileptics, not otherwise specified; 4-6
Service Code
80340 (CPT) Antiepileptics, not otherwise specified; 4-6
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Antiepileptics, not otherwise specified; 7 or more
Service Code
80341 (CPT) Antiepileptics, not otherwise specified; 7 or more
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Antipsychotics, not otherwise specified; 1-3
Service Code
80342 (CPT) Antipsychotics, not otherwise specified; 1-3
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Antipsychotics, not otherwise specified; 4-6
Service Code
80343 (CPT) Antipsychotics, not otherwise specified; 4-6
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Antipsychotics, not otherwise specified; 7 or more
Service Code
80344 (CPT) Antipsychotics, not otherwise specified; 7 or more
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
80345 BARBITURATES LEVELS
Service Code
80345 (CPT) 80345 BARBITURATES LEVELS
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
80346 BENZODIAZEPINES LEVELS
Service Code
80346 (CPT) 80346 BENZODIAZEPINES LEVELS
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
80353 DRUG SCREENING COCAINE
Service Code
80353 (CPT) 80353 DRUG SCREENING COCAINE
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Gabapentin, non-blood
Service Code
80355 (CPT) Gabapentin, non-blood
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Pregabalin
Service Code
80366 (CPT) Pregabalin
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Stereoisomer (enantiomer) analysis, single drug class
Service Code
80374 (CPT) Stereoisomer (enantiomer) analysis, single drug class
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 1-3
Service Code
80375 (CPT) Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 1-3
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 4-6
Service Code
80376 (CPT) Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 4-6
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 7 or more
Service Code
80377 (CPT) Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 7 or more
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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