Prior Authorization Form

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
  • 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: Opthamology authorizations will be for surgical procedure only not place of service)
  • (Potentially) Cosmetic Procedures (ex: Breast Reduction & Reconstruction, Blepharoplasty, Strabismus)
  • DME purchases over $1,000
  • Prosthetics and orthotics over $2,000
  • MRI scan, MRA scans, Pet scan
  • Pain Management services (epidurals, implantable infusion pumps, etc…) - including Honor Health Providers
  • Surgical treatment of TMJ conditions
  • Home health care- (including Honor Health Home Care)
  • Home infusion therapy services
  • Specialty infusion/injectable medications which are covered under the Medical Benefits and not obtained through the Prescription Drug Benefits - See ICP List:
  • Transplants: bone marrow, stem cell, heart, intestine, kidney, liver, lung, pancreas.
  • Experimental or Investigational treatments or surgeries (including Clinical Trials)
  • Genetic Testing Lab Fees and Counseling- (including Honor Health providers)
  • Services at any post-acute facility (SNF, AIR, LTAC, etc)
  • Ambulance Services (non-emergent)
  • Hyperbaric Oxygen Testing
  • Ventricular Assistive Device (VAD); Life Vests; Implantable Cardiac Defibrillators
  • Proton Beam Therapy
  • Speech Therapy
  • Testosterone Hormone Therapy for Males
  • Outpatient Dialysis


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:

  • Blood-clotting factors
  • Botulinum toxin type A and B: Botox®, Dysport® , and Myobloc
  • C1 Inhibitors: Cinryze and Berinert
  • Blood cell deficiency/erythropoiesis stimulating agents (ESA): Epoetin, Darbepoetin, and Oprelvekin
  • Growth hormones
  • Growth hormone blocker: Mecasermin
  • Immunologic agents/immune modulators/biologics/monoclonal antibody agents : Abatacept (Orencia®), Adalimumab (Humira®), Amevive®, Anakinra (Kineret®), Belimumab, Certolizumab (Cimzia®), Etanercept (Enbrel®), Eculizumab (Soliris), Fingolimod (Gilenya), Glatiramer Acetate (Copaxone, Glatopa), Golimumab (Simponi®), Pembrolizumab (Keytruda, Opdivo), Infliximab (Remicade®), Rituximab (Rituxan®), Secukinumab (Cosentyx), Tofacitinib (Actemra®), Ustekinumab (Stelara®), and Vedolizumab (Entyvio®)
  • Immunoglobulins, includes any parenteral administration [intravenous (IV), subcutaneous (SubQ), and/or intramuscular (IM)]
  • Bone condition agents: Prolia®, Zometa, and/or Pamidronate (Aredia®)
  • Miscellaneous specialty medications, such as Spinraza (nusinersen), Exondys 51 (eteplirsen), and Brineura (cerliponase alfa)
  • Respiratory conditions: Omalizumab (Xolair) and Mepolizumab (Nucala)
  • Eye conditions: Afibercept (Eylea) and Ranibizumab (Lucentis)
  • Enzyme deficiency: Agalsidase Beta (Fabrazyme) and Pegloticase (Krystexxa),
  • Endocrine disorders: Octreotide (Sandostatin), Lanreotide (Somatuline Depot), and Pasireotide (Signifor LAR)

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

  • Centers for Medicare and Medicaid Services (CMS) Criteria

  • American College of Obstetrics and Gynecology

  • The American Academy of Pediatrics

  • Innovation Care Partners Evidence Based Clinical Protocols

  • The Department of Health and Human Services Health Care Guidelines

  • ICP uses nationally recognized clinical criteria in order to make evidence based UM decisions. These criteria are available to upon request, by contacting (480) 400-0001.


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


Main Number: 480-400-0001


Karen Vanaskie DNP, MSN, RN

Voice Mail: 480-630-1049

Email:kvanaskie@icphealth.com

Mobile: 602-571-9919


Peggy Tyndall MBA, RN

Voice Mail: 480-696-4028

Email: ptyndall@icphealth.com

Mobile: 253-576-7576





Utilization Review Nurse

Local Voice Mail: 480-630-1376 or 480-681-6502

Out of Area: 1-800-250-6991

E-mail: icpur@icphealth.com


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