Prior Authorization Form

Medical Management Satisfaction Survey

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)
  • DME purchases over $1,000
  • Prosthetics and orthotics over $2,000
  • MRI scan, MRA scans, Pet scan
  • 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 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 - (All genetics testing must have 3rd party pre - test Counseling documentation to obtain PA 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

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 (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:

  • Botulinum toxin type A and B: Botox®, Dysport®, Jeuveau®, Myobloc®, and Xeomin®
  • 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®)
  • Immunologic agents/immune modulators/biologics/monoclonal antibody agents: Abatacept (Orencia®), Adalimumab (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®), and onasemnogene abeparvovec (Zolgensma®)
  • 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 Medication Listing

  • Copaxone
  • Cosentyx
  • Enbrel
  • Gilenya
  • Humira
  • Hyqvia
  • Norditropin
  • Omnitrope
  • Simponi
  • Stelara
  • Xolair
The medications on the "Medical Management Required 340-B Prior Authorization Medication List" 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 FDA, CMS, CDC, PubMed

  • Clinical practice guidelines by National Associations when available

  • Innovation Care Partner’s Physician developed evidence-based guidelines

  • Medical Management Benefit Prescription Drug Criteria References

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


Main Number: 480-400-0001


Karen Vanaskie DNP, MSN, RN

Voice Mail: 480-630-1049

Email:kvanaskie@icphealth.com





Utilization Review Nurse

Local Voice Mail: 480-681-6502

Out of Area: 1-800-250-6991

E-mail: icpur@icphealth.com



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