Prior authorization codes
Driscoll Health Plan
Active CPT codes that appear on the extracted prior authorization list for this health plan.
| Code | Procedure / Service | Effective | Revised | Confidence | Source |
|---|---|---|---|---|---|
| 0001A | PR IMM ADMN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0002A | PR IMM ADMN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0003A | COVID-19 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0004A | IMMUNIZATION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 00103 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0011A | PR IMM ADMN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 8/12/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0012A | PR IMM ADMN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 8/12/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0013A | COVID-19 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 8/12/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 00170 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK C, CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0031A | PR IMM ADMN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 8/12/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0034A | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0041A | PR IMM ADMN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0042A | PR IMM ADMN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0044A | ADM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0051A | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0052A | IMMUNIZATION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0053A | IMMUNIZATION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0054A | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0064A | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0071A | PR FIRST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0072A | PR SECOND NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 00731 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 00732 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0073A | IMMUNIZATION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0074A | IMMUNIZATION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 00811 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 00812 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 00813 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0081A | PR IMM ADMIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0082A | PR IMM ADMN 2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0083A | PR IMM ADMN 2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0091A | MODERNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0092A | MODERNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0093A | MODERNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0094A | ADM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0111A | PR IMM ADMIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 3/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0112A | PR IMM ADMN 2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 3/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0113A | MODERNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 3/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0121A | ADM SARSCV2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0124A | ADM SARSCV2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0134A | ADM SARSCV2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0141A | ADM SRSCV2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0142A | ADM SRSCV2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0144A | ADM SARSCV2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0151A | ADM SARSCV2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0154A | IMMUNIZATION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0164A | MODERNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 3/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0171A | ADM SARSCV2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0172A | ADM SARSCV2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0173A | PFIZER- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0174A | IMM ADMN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01916 | PR ANESTH,DX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01917 | SPECIALTY( ), PET | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01918 | SPECIALTY( ), PET | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01919 | SPECIALTY( ), PET | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01920 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01921 | SPECIALTY( ), PET | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01922 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01923 | SPECIALTY( ), PET | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01924 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01925 | ANESTH,INTER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01926 | ANESTH,INTER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01927 | SPECIALTY( ), PET | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01928 | SPECIALTY( ), PET | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01929 | SPECIALTY( ), PET | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01930 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01931 | ANESTH,INTER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01932 | ANESTH,INTER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01933 | ANESTH,INTER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01934 | SPECIALTY( ), PET | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01935 | SPECIALTY( ), PET | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01936 | SPECIALTY( ), PET | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01937 | PR ANES PERQ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01938 | PR ANES PERQ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01939 | PR ANES PERQ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01940 | PR ANES PERQ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01941 | PR ANES PERQ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 01942 | PR ANES PERQ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0537T | PR CAR-T AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0538T | PR CAR-T AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0539T | PR CAR-T AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0540T | PR CAR-T AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0604T | PR REMOTE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0605T | PR REM OCT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0606T | PR REMOTE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0616T | PR INSJ IRIS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0617T | PR INSJ IRIS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0618T | PR INSJ IRIS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0621T | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 0622T | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 10004 | PR FINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 10005 | PR FINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 10006 | PR FINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 10007 | PR FINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 10008 | PR FINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 10009 | PR FINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 10010 | PR FINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 10011 | PR FINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 10012 | PR FINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 10021 | PR FINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 10040 | PR ACNE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 10060 | PR DRAIN SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 10061 | PR DRAIN SKIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 10080 | PR DRAIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 10081 | PR DRAIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 10120 | PR REMOVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 10121 | PR REMOVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 10140 | PR DRAINAGE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 10160 | PR PUNCTURE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 10180 | PR COMPLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11042 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11043 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11044 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11045 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11046 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11047 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11055 | PR TRIM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11056 | TRIM BENIGN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11057 | TRIM BENIGN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11102 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11103 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11104 | PR PUNCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11105 | PR PUNCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11106 | PR INCISIONAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11107 | PR INCISIONAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11400 | PR EXC SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11401 | PR EXC SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11402 | PR EXC SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11403 | PR EXC SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11404 | PR EXC SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11420 | PR EXC SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11421 | PR EXC SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11422 | PR EXC SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11423 | PR EXC SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11426 | PR EXC SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11440 | PR EXC SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11441 | PR EXC SKIN AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11442 | PR EXC SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11443 | PR EXC SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11444 | PR EXC SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11719 | PR TRIM NAIL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11720 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11721 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11730 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11732 | PR REMOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11750 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11752 | PR REMOVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11755 | PR BIOPSY, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11765 | PR EXCISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11770 | PR REMV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11771 | PR REMV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11772 | PR REMV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11900 | INJECTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11901 | INJECTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11920 | PR CORRECT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11921 | PR CORRECT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11922 | PR CORRECT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11950 | PR FILL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11951 | PR FILL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11952 | PR FILL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11954 | PR FILL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11976 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK C, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11980 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK C, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11981 | PR INSERTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK C, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11982 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK C, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 11983 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK C, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 12031 | PR LAYR CLOS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 12032 | PR LAYR CLOS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 14000 | PR ADJ TISS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 14001 | PR ADJ TISS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 14020 | PR ADJ TISS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 14021 | PR ADJ TISS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 14040 | PR ADJ TISS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 14041 | PR ADJ TISS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 14060 | PR ADJ TISS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 14061 | PR ADJ TISS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 14301 | PR ADJ TISS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 14302 | PR ADJT TIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15002 | PR WOUND NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15003 | PR WOUND NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15004 | PR WND PREP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15005 | PR WND NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15040 | PR SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15050 | PR SKIN PINCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15271 | ACELL GRAFT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15272 | PR APP SKN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15273 | PR APP SKN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15274 | PR APP SKN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15275 | PR SUB GRFT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15276 | PR SUB GRFT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15277 | PR SUB GRFT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15278 | PR SUB GRFT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15570 | PR FORM SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15572 | PR FORM SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15574 | PR FORM SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15576 | PR FORM SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15630 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15730 | PR MIDFACE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15731 | PR FOREHEAD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15733 | PR MUSC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15734 | PR MUSCLE- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15736 | PR MUSCLE- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15738 | PR MUSCLE- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15740 | PR FLAP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15750 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15756 | PR FREE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15757 | PR FREE SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15758 | PR FREE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15760 | PR COMPOSITE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15769 | PR GRAFTING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15770 | PR DERMA- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15771 | PR GRAFTING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15772 | PR GRAFTING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15773 | PR GRAFTING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15774 | PR GRAFTING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15775 | PR HAIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15776 | PR HAIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15777 | PR IMPLNT BIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15778 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15780 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15781 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15782 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15783 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15786 | PR ABRASION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15787 | PR ABRASION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15788 | PR CHEM PEEL, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15789 | PR CHEM PEEL, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15792 | PR CHEM PEEL, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15793 | PR CHEM PEEL, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15819 | PR PLASTIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15820 | PR REVISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15821 | PR REV LOWER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15822 | PR REVISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15823 | PR REV UPPER AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15824 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15825 | PR REMOV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15826 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15828 | PR REML OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15829 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15830 | PR EXCISE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15831 | PR EXCISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15832 | PR EXCISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15833 | PR EXCISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15834 | PR EXCISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15835 | PR EXCISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15836 | PR EXCISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15837 | PR EXCISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15838 | PR EXCISE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15839 | PR EXCISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15840 | PR GRAFT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15841 | PR GRAFT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15842 | PR GRAFT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15845 | PR GRAFT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15851 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15876 | PR SUCT ASSIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15877 | PR SUCT ASSIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15878 | PR SUCT ASSIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 15879 | PR SUCT ASSIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 16000 | PR INITIAL RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 16020 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 16025 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 16030 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 16035 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 16036 | PR INCISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 17106 | PR DESTRUC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 17107 | PR DESTRUC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 17108 | PR DESTRUC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 17110 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 17111 | DESTRUCTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 17340 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 17360 | PR SKIN PEEL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 17380 | PR HAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 17999 | PR SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19081 | PR BX BREAST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19082 | PR BX BREAST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19083 | PR BX BREAST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19084 | PR BX BREAST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19085 | PR BX BREAST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19086 | PR BX BREAST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19100 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19101 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19300 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19316 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19318 | PR BREAST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19324 | PR ENLARGE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19325 | PR BREAST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19328 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19330 | PR RMVL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19364 | PR BREAST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19367 | PR BREAST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19368 | PR BREAST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19369 | PR BREAST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19370 | PR REVISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19371 | PR PERI- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19380 | PR REVISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 19396 | PR DESIGN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20200 | PR MUSCLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20205 | PR DEEP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20206 | PR NEEDLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20220 | PR BONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20225 | PR BONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 2022F | PR DILATED AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 2023F | PR DILATED AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20240 | PR BIOPSY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20245 | PR BIOPSY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20250 | PR OPEN BONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20251 | PR OPEN BONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20520 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20525 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20550 | PR INJECT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20600 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20604 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20605 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20606 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20610 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20611 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20612 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20615 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20665 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20670 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20680 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20693 | PR ADJUST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20694 | PR REMOVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20696 | PR COMP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 20697 | PR COMP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21025 | PR EXCISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21026 | PR EXCISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21029 | PR CONTOUR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21030 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21031 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21032 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21034 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21040 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21044 | PR REMV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21083 | PR PREP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21086 | PR PREP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21087 | PR PREP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21120 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21121 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21122 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21123 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21125 | PR AUGMENT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21127 | PR AUGMENT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21137 | PR REDUC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21138 | PR REDUC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21139 | PR REDUC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21141 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21142 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21143 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21145 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21146 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21147 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21150 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21151 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21154 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21155 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21159 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21160 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21172 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21175 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21179 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21180 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21181 | PR CONTOUR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21182 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21183 | PR RECON NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21188 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21208 | PR AUGMENT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21209 | PR REDUCTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21210 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21215 | PR MANDIBLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21230 | PR RIB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21235 | PR EAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21240 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21242 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21243 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21244 | PR RECONSTR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21245 | PR RECONSTR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21246 | PR RECONSTR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21247 | PR RECONSTR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21248 | PR RECONSTR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21249 | PR RECONSTR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21255 | PR RECONSTR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21256 | PR RECONSTR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21260 | PR REVISE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21261 | PR REVISE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21263 | PR REVISE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21267 | PR REPOSITN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21268 | PR REPOSITN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21270 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21275 | PR REVISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21280 | PR REVISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21282 | PR REVISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21295 | PR REVISN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21296 | PR REVISN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21315 | PR CLOSED TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21320 | PR CLOSED TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21325 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21330 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21335 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21336 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21337 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21338 | PR REPAIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21339 | PR REPAIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21340 | PR REPAIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21343 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21344 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21345 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21346 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21347 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21348 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21355 | PR CLOSED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21356 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21360 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21365 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21366 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21385 | PR REPAIR EYE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21386 | PR REPAIR EYE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21387 | PR REPAIR EYE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21390 | PR REPAIR EYE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21395 | PR REPAIR EYE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21400 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21401 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21406 | PR OPEN RX FX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21407 | PR OPEN RX FX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21408 | PR OPEN RX FX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21421 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21422 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21423 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21431 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21432 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21433 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21435 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21436 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21440 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21445 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21450 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21451 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21452 | PR PERCUT RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21453 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21454 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21461 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21462 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21465 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21470 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21480 | PR REDUCE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21485 | PR REDUCE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21490 | PR OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21493 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21494 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21495 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21510 | PR INCIS BONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21550 | PR BIOPSY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21740 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21742 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21743 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21800 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21805 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21810 | PR RX RIB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21811 | PR OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21812 | PR OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21813 | PR OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21820 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21825 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21920 | PR BIOPSY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 21925 | PR BIOPSY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 22305 | PR CLOSED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 22856 | PR TOT DISC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 22858 | PR TOT DISC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 22861 | PR REVISION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 22864 | PR REMOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23000 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23020 | PR RELEASE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23030 | PR INCIS/DRAIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23031 | PR DRAIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23035 | PR DRAIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23040 | PR DEEP INCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23044 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23065 | PR EXPLOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23066 | PR BIOPSY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23071 | PR EXCISION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23073 | PR EXC TUMOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23075 | PR BIOPSY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23076 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23077 | PR RAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23078 | PR RAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23100 | PR OPEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23101 | PR OPEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23105 | PR REMOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23106 | PR REMOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23107 | PR EXPLORE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23120 | PR PARTIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23125 | PR TOTAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23130 | PR PARTIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23140 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23145 | PR EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23146 | PR EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23150 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23155 | PR EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23156 | PR EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23170 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23172 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23174 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23180 | PR PART EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23182 | PR PART EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23184 | PR PART EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23190 | PR PART REMV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23195 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23200 | PR RAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23210 | PR RAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23220 | PR RAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23221 | PR RAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23222 | PR RAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23330 | PR REMOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23331 | PR REMOVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23332 | PR REMOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23333 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23334 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23335 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23350 | PR INJ PROC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23395 | PR MUSCLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23397 | PR MUSCLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23400 | PR FIXATION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23405 | PR INCISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23406 | PR INCISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23410 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23412 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23415 | PR CORACO- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23420 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23430 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23440 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23450 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23455 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23460 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23462 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23465 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23466 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23470 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23472 | PR RECONSTR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23473 | PR REVIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23474 | PR REVIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23480 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23485 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23490 | PR REINFORCE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23491 | PR REINFORCE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23500 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23505 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23515 | OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23520 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23525 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23530 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23532 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23540 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23545 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23550 | PR OPEN RX A- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23552 | PR OPEN RX A- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23570 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23575 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23585 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23600 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23605 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23615 | OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23616 | OPEN PROX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23620 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23625 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23630 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23650 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23655 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23660 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23665 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23670 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23675 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23680 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23700 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23800 | PR FUSION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23802 | PR FUSION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23900 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23920 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23921 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23929 | PR SHOULDER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23930 | PR INCIS/DRAIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23931 | PR INCIS/DRAIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 23935 | PR INCIS DEEP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24000 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24006 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24065 | PR BX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24066 | PR BX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24071 | PR EXC TUMOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24073 | PR EXC TUMOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24075 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24076 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24077 | PR RAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24079 | PR RAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24100 | PR BIOPSY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24101 | PR EXPLORE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24102 | PR EXPLOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24105 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24110 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24115 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24116 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24120 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24125 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24126 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24130 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24134 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24136 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24138 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24140 | PR PARTIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24145 | PR PARTIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24147 | PR PARTIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24149 | PR RADICAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24150 | PR RADICAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24151 | PR RAD RESEC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24152 | PR RADICAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24153 | PR RAD RESEC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24155 | PR RESECTION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24160 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24164 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24200 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24201 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24220 | PR INJECTION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24300 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24301 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24305 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24310 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24320 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24330 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24331 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24332 | PR TENOLYSIS, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24340 | PR REPAIR OF AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24341 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24342 | PR REINSERT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24343 | PR REPR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24344 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24345 | PR REPR ELBW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24346 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24350 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24351 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24352 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24354 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24356 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24357 | PR TENOTOMY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24358 | PR TENOTOMY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24359 | PR TENOTOMY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24360 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24361 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24362 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24363 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24365 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24366 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24370 | PR REVIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24371 | PR REVIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24400 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24410 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24420 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24430 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24435 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24470 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24495 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24498 | PR REINFORCE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24500 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24505 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24515 | PR OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24516 | PR OPEN ROD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24530 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24535 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24538 | PR PERCUT FIX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24545 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24546 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24560 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24565 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24566 | PR PERCUT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24575 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24576 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24577 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24579 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24582 | PR PERCUT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24586 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24587 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24600 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24605 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24615 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24620 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24635 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24640 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24650 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24655 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24665 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24666 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24670 | CLOSED TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24675 | CLOSED TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24685 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24800 | PR FUSION OF AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24802 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24900 | PR AMPUTATN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24920 | PR AMPUTATN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24925 | PR AMPUTATN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24930 | PR RE- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24931 | PR AMPUTATE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24935 | PR STUMP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24940 | PR REVISION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 24999 | PR UPPER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25000 | PR INCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25001 | PR INCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25020 | PR DECOMP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25023 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25024 | PR DECOMP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25025 | PR DECOMP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25028 | PR INCIS/DRAIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25031 | PR INCIS/DRAIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25035 | PR INCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25040 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25065 | PR BIOPSY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25066 | PR BIOPSY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25071 | PR EXC TUMOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25073 | EXC FOREARM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25075 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25076 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25077 | PR RAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25078 | PR RAD RESCJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25085 | PR INCISION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25100 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25101 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25105 | PR EXPLOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25107 | PR REPAIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25109 | PR EXCISE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25110 | PR EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25111 | PR EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25112 | PR EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25115 | PR RAD EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25116 | PR RAD EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25118 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25119 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25120 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25125 | PR EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25126 | PR EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25130 | PR EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25135 | PR EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25136 | PR EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25145 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25150 | PR PART AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25151 | PR PART AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25170 | PR RAD RESEC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25210 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25215 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25230 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25240 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25246 | PR INJECTION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25248 | PR REMOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25250 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25251 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25259 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25260 | PR REPR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25263 | PR REPR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25265 | PR REPR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25270 | PR REPR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25272 | PR REPR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25274 | PR REPR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25275 | PR REPR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25280 | PR REVISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25290 | PR INCISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25295 | PR RELEASE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25300 | PR FUSION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25301 | PR FUSION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25310 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25312 | PR XPLANT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25315 | PR REVISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25316 | PR REVISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25320 | PR REVISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25332 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25335 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25337 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25350 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25355 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25360 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25365 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25370 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25375 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25390 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25391 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25392 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25393 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25394 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25400 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25405 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25415 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25420 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25425 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25426 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25430 | PR INSERT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25431 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25440 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25441 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25442 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25443 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25444 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25445 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25446 | PR TOTAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25447 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25449 | PR REMOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25450 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25455 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25490 | PR REINFORCE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25491 | PR REINFORCE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25492 | PR REINFORCE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25500 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25505 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25515 | OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25520 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25525 | OPEN RDL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25526 | OPEN RDL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25530 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25535 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25545 | OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25560 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25565 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25574 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25575 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25600 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25605 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25606 | PR PERCUT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25607 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25608 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25609 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25611 | PR PERCUT FIX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25620 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25622 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25624 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25628 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25630 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25635 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25645 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25650 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25651 | PR PERCUT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25652 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25660 | PR CLOSED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25670 | PR OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25671 | PR PERCUT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25675 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25676 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25680 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25685 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25690 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25695 | PR OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25800 | PR FUSION OF AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25805 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25810 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25820 | PR FUSION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25825 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25830 | PR FUSION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25900 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25905 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25907 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25909 | PR RE- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25915 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25920 | PR AMPUTATE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25922 | PR AMPUTATE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25924 | PR RE- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25927 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25929 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25931 | PR RE- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 25999 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26010 | PR DRAIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26011 | PR DRAIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26020 | PR DRAIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26025 | PR DRAINAGE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26030 | PR DRAINAGE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26034 | PR INCIS DEEP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26035 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26037 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26040 | PR RELEASE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26045 | PR RELEASE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26055 | PR INCISE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26060 | PR INCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26070 | PR EXPLORE & AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26075 | PR EXPLORE & AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26080 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26100 | PR BIOPSY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26105 | PR BIOPSY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26110 | PR BIOPSY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26111 | PR EX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26113 | PR EX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26115 | PR EXCIS SOFT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26116 | PR EXCIS SOFT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26117 | PR RAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26118 | PR RAD RESCJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26121 | PR PALMAR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26123 | PR PART AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26125 | PR PART AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26130 | PR EXCIS JT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26135 | PR EXCIS JT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26140 | PR EXCIS JT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26145 | PR RAD EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26160 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26170 | PR EXCIS PALM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26180 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26185 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26200 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26205 | PR EXCIS/GRFT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26210 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26215 | PR EXCIS/GRFT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26230 | PR PART REMV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26235 | PR PART REMV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26236 | PR PART REMV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26250 | PR RAD RESEC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26255 | PR RAD RESEC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26260 | PR RAD RESEC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26261 | PR RAD RESEC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26262 | PR RAD RESEC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26320 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26340 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26341 | PR MANIPLATN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26350 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26352 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26356 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26357 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26358 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26370 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26372 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26373 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26390 | PR EXCIS FLEX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26392 | PR REMOV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26410 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26412 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26415 | PR EXCIS EXT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26416 | PR REMOV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26418 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26420 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26426 | PR REPAIR EXT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26428 | PR REPAIR EXT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26432 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26433 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26434 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26437 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26440 | PR TENOLYSIS, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26442 | PR TENOLYSIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26445 | PR TENOLYSIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26449 | PR RELEASE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26450 | PR TENOTOMY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26455 | PR TENOTOMY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26460 | PR TENOTOMY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26471 | PR FUSION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26474 | PR FUSION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26476 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26477 | PR TENDON AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26478 | PR TENDON AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26479 | PR TENDON AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26480 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26483 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26485 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26489 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26490 | PR REVISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26492 | PR THUMB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26494 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26496 | PR REVISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26497 | PR FINGER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26498 | PR FINGER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26499 | PR CORRECT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26500 | PR HAND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26502 | PR HAND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26504 | PR HAND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26508 | PR RELEASE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26510 | PR CROSS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26516 | PR FUSION MC- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26517 | PR FUSION MC- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26518 | PR FUSION MC- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26520 | PR RELEASE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26525 | PR RELEASE I- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26530 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26531 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26535 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26536 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26540 | PR FIX COLLAT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26541 | PR FIX COLLAT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26542 | PR FIX COLLAT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26545 | PR FIX COLAT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26546 | PR FIX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26548 | PR FIX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26550 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26551 | PR GREAT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26553 | PR SINGLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26554 | PR DOUBLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26555 | PR POSITIONAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26556 | PR FREE TOE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26560 | PR REPAIR OF AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26561 | PR REPAIR OF AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26562 | PR REPAIR OF AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26565 | PR CORRECT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26567 | PR CORRECT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26568 | PR LENGTHEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26580 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26587 | PR RECONST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26590 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26591 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26593 | PR RELEASE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26596 | PR EXCISION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26600 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26605 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26607 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26608 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26615 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26641 | PR TREAT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26645 | PR TREAT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26650 | PRQ SKEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26665 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26670 | PR CLOSED RX, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26675 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26676 | PR PERCUT FIX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26685 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26686 | PR OPEN RX C- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26700 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26705 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26706 | PR PERCUT RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26715 | OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26720 | PR CLOSE RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26725 | PR CLOSE RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26727 | PR PERCUT RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26735 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26740 | PR CLOSE RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26742 | PR CLOSE RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26746 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26750 | PR CLOSE RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26755 | PR CLOSE RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26756 | PR PERCUT RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26765 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26770 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26775 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26776 | PR PERCUT RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26785 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26820 | PR THUMB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26841 | PR FUSION 1ST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26842 | PR FUSION 1ST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26843 | PR FUSION 2-5 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26844 | PR FUSION 2-5 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26850 | PR FUSION MC- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26852 | PR FUSION MC- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26860 | PR FUSION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26861 | PR FUSION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26862 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26863 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26910 | PR AMPUTATE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26951 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26952 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26989 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26990 | PR INCIS/DRAIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26991 | PR INCIS/DRAIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 26992 | PR INCIS/DRAIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27000 | PR INCIS HIP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27001 | PR INCIS HIP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27003 | PR INCIS HIP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27005 | PR INCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27006 | PR INCIS HIP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27025 | PR INCIS OF AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27027 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27030 | PR DRAINAGE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27033 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27035 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27036 | PR RELEASE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27040 | PR BX SOFT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27041 | PR BX SOFT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27043 | PR EXCISION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27045 | PR EXC TUMOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27047 | PR REMOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27048 | PR REMOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27049 | PR RAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27050 | PR OPEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27052 | PR OPEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27054 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27057 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27059 | PR RAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27060 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27062 | PR REMOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27065 | PR EXCISISON AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27066 | PR EXCISISON AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27067 | PR EXCISISON AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27070 | PR PARTIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27071 | PR PARTIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27075 | PR RAD RESEC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27076 | PR RAD RESEC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27077 | PR RAD RESEC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27078 | PR RAD RESEC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27079 | PR RAD RESEC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27080 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27086 | PR REMOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27087 | PR REMOVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27090 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27091 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27093 | PR INJECTION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27095 | PR INJECTION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27096 | PR INJECT SI AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27097 | PR HAMSTRING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27098 | PR ADDUCTOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27100 | PR XFER ABD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27105 | PR XFER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27110 | PR XFER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27111 | PR XFER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27120 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27122 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27125 | PR PARTIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27130 | PR TOTAL HIP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27132 | PR CONV PREV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27134 | PR REVISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27137 | PR REVISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27138 | PR REVISE FEM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27140 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27146 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27147 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27151 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27156 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27158 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27161 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27165 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27170 | PR BONE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27175 | PR CLOSED RX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27176 | PR CLOSED RX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27177 | PR OPEN RX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27178 | PR OPEN RX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27179 | PR OPEN RX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27181 | PR OPEN RX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27185 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27187 | PR REINFORCE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27197 | PR CLSD TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27198 | PR CLSD TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27200 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27202 | PR OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27215 | PR OPEN FIX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27216 | PR PERCUT FIX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27217 | PR OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27218 | PR OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27220 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27222 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27226 | PR OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27227 | PR OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27228 | PR OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27230 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27232 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27235 | PR PERCUT FIX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27236 | PR FEMORAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27238 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27240 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27244 | PR TREAT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27245 | PR OPEN FIX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27246 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27248 | OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27250 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27252 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27253 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27254 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27256 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27257 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27258 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27259 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27265 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27266 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27267 | PR CLOSED TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27268 | PR CLOSED TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27269 | PR OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27275 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27278 | ARTHRD SI JT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27279 | ARTHRODESIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27280 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27282 | PR FUSION OF AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27284 | PR FUSION HIP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27286 | PR FUSION HIP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27290 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27295 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27299 | PR PELVIS/HIP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27301 | PR INCIS/DRAIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27303 | PR INCIS DEEP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27305 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27306 | PR INCIS THIGH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27307 | PR INCIS THIGH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27310 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27323 | PR BX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27324 | PR BX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27325 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27326 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27327 | PR REMV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27328 | PR REMV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27329 | PR RAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27330 | PR BIOPSY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27331 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27332 | PR EXCIS KNEE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27333 | PR EXCIS KNEE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27334 | PR RMV KNEE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27335 | PR REMV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27337 | PR EXCISON AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27339 | PR EXC TUMOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27340 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27345 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27347 | PR REMOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27350 | PR PART/FULL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27355 | PR REMV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27356 | PR REMV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27357 | PR REMV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27358 | PR REMV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27360 | PR PART REMV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27364 | PR RAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27365 | PR RAD RESEC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27369 | PR NJX PX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27370 | PR INJECTION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27372 | PR REMV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27380 | PR FIX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27381 | PR FIX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27385 | PR FIX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27386 | PR FIX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27390 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27391 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27392 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27393 | PR LENGTHEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27394 | PR LENGTHEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27395 | PR LENGTHEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27396 | PR XPLANT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27397 | PR XPLANT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27400 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27403 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27405 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27407 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27409 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27412 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27415 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27416 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27418 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27420 | PR REVISION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27422 | PR FIX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27424 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27425 | PR LATERAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27427 | PR LIGMT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27428 | PR LIGMT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27429 | PR LIGMT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27430 | PR REVISION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27435 | PR POST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27437 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27438 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27440 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27441 | PR PLASTY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27442 | PR PLASTY TIB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27443 | PR PLASTY TIB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27445 | PR PLASTY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27446 | PR PLASTY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27447 | PR TOTAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27448 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27450 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27454 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27455 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27457 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27465 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27466 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27468 | PR COMBINE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27470 | PR FIX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27472 | PR FIX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27475 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27477 | PR SURGERY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27479 | PR SURGERY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27485 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27486 | PR REVISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27487 | PR REVISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27488 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27495 | PR REINFORCE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27496 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27497 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27498 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27499 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27500 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27501 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27502 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27503 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27506 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27507 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27508 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27509 | PR PERCUT FIX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27510 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27511 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27513 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27514 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27516 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27517 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27519 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27520 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27524 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27530 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27532 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27535 | OPEN TX TIBIAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27536 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27538 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27540 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27550 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27552 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27556 | OPEN TX KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27557 | OPEN TX KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27558 | OPEN TX KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27560 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27562 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27566 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27570 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27580 | PR FUSION OF AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27590 | PR AMPUTATE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27591 | PR AMPUTATE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27592 | PR AMPUTATE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27594 | PR AMPUTATE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27596 | PR AMPUTATE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27598 | PR AMPUTATE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27599 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27600 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27601 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27602 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27603 | PR DRAIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27604 | PR DRAIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27605 | PR INCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27606 | PR INCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27607 | PR DRAIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27610 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27612 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27613 | PR BX LOW NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27614 | PR BX LOW NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27615 | PR RAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27616 | PR RAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27618 | PR RESEC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27619 | PR RESEC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27620 | PR EXPLOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27625 | PR EXPLOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27626 | PR EXPLOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27630 | PR EXCIS LESN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27632 | PR EXCISION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27634 | PR EXC TUMOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27635 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27637 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27638 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27640 | PR PARTIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27641 | PR PARTIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27645 | PR RAD RESEC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27646 | PR RAD RESEC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27647 | PR RAD RESEC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27648 | PR INJECTION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27650 | PR REPAIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27652 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27654 | PR REPAIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27656 | PR REPAIR LEG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27658 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27659 | PR REPAIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27664 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27665 | PR REPAIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27675 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27676 | PR REPAIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27680 | PR RELEASE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27681 | PR RELEASE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27685 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27686 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27687 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27690 | PR XFER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27691 | PR XFER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27692 | PR XFER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27695 | PR REPAIR 1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27696 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27698 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27700 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27702 | PR TOTAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27703 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27704 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27705 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27707 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27709 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27712 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27715 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27720 | RPR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27722 | RPR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27724 | RPR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27725 | RPR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27726 | PR RPR FIBULA AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27727 | RPR CONGEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27730 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27732 | PR STOP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27734 | PR STOP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27740 | PR STOP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27742 | PR STOP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27745 | PR REINFORCE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27750 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27752 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27756 | PR PERCUT RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27758 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27759 | PR TREAT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27760 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27762 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27766 | OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27767 | PR CLOSED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27768 | PR CLOSED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27769 | PR OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27780 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27781 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27784 | OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27786 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27788 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27792 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27808 | CLOSED TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27810 | CLOSED TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27814 | OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27816 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27818 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27822 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27823 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27824 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27825 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27826 | OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27827 | OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27828 | OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27829 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27830 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27831 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27832 | OPEN TX PROX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27840 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27842 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27846 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27848 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27860 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27870 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27871 | PR FUSION OF AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27880 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27881 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27882 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27884 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27886 | PR RE- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27888 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27889 | PR ANKLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27892 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27893 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27894 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 27899 | PR LEG/ANKLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28001 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28002 | PR DEEP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28003 | PR DEEP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28005 | PR DEEP INCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28008 | PR INCISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28010 | PR INCISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28011 | PR INCISION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28020 | PR EXPLOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28022 | PR EXPLOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28024 | PR EXPLOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28030 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28035 | PR TARSAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28039 | EXC FOOT/TOE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28041 | PR EXC TUMOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28043 | PR EXCIS FOOT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28045 | PR EXCIS FOOT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28046 | PR RAD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28047 | PR RAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28050 | PR BX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28052 | PR BX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28054 | PR BX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28055 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28060 | PR PART EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28062 | PR RAD EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28070 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28072 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28080 | PR EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28086 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28088 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28090 | PR EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28092 | PR EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28100 | PR REMV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28102 | PR REMV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28103 | PR REMV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28104 | PR REMV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28106 | PR REMV OTHR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28107 | PR REMV OTHR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28108 | PR REMV TOE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28110 | PR PART EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28111 | PR FULL EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28112 | PR FULL EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28113 | PR FULL EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28114 | PR FULL EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28116 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28118 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28119 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28120 | PR PART REMV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28122 | PR PART REMV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28124 | PR PART REMV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28126 | PR RESEC ONE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28130 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28140 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28150 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28153 | PR RESEC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28160 | PR RESEC TOE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28171 | PR RAD RESEC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28173 | PR RAD RESEC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28175 | PR RAD RESEC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28190 | PR REMV FOOT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28192 | PR REMV FOOT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28193 | PR REMV FOOT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28200 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28202 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28208 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28210 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28220 | PR RELEASE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28222 | PR RELEASE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28225 | PR RELEASE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28226 | PR RELEASE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28230 | PR INCISION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28232 | PR INCISION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28234 | PR INCISION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28238 | PR RECONST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28240 | PR RELEASE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28250 | PR DIVISN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28260 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28261 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28262 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28264 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28270 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28272 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28280 | PR FUSION OF AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28285 | PR REPAIR OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28286 | PR REPAIR 5TH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28288 | PR PART REMV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28289 | PR HALLUX NO AUTHORIZATION REQUIRED MD GUIDELINE 1 CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28290 | PR CORRECT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28291 | PR HALLUX NO AUTHORIZATION REQUIRED MD GUIDELINE 1 CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28292 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28293 | PR CORRECT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28294 | PR CORRECT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28295 | PR NO AUTHORIZATION REQUIRED MD GUIDELINE 1 CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28296 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28297 | PR CORRJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28298 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28299 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28300 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28302 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28304 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28305 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28306 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28307 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28308 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28309 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28310 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28312 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28313 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28315 | PR REMOV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28320 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28322 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28340 | PR RESECT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28341 | PR RESECT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28344 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28345 | PR REPAIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28360 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28400 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28405 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28406 | PR PERCUT RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28415 | OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28420 | OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28430 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28435 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28436 | PR PERCUT RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28445 | OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28446 | PR OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28450 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28455 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28456 | PR PERCUT RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28465 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28470 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28475 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28476 | PR PERCUT RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28485 | OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28490 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28495 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28496 | PR PERCUT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28505 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28510 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28515 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28525 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28530 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28531 | PR OPEN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28540 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28545 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28546 | PR PERCUT RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28555 | OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28570 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28575 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28576 | PR PERCUT RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28585 | OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28600 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28605 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28606 | PR PERCUT RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28615 | OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28630 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28635 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28636 | PR PERCUT RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28645 | OPEN TX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28660 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28665 | PR CLOSED RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28666 | PR PERCUT RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28675 | OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28705 | PR FUSION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28715 | PR FUSION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28725 | PR FUSION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28730 | PR FUSION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28735 | PR FUSION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28737 | PR FUSION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28740 | PR FUSION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28750 | PR FUSION BIG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28755 | PR FUSION BIG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28760 | PR FUSION BIG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28800 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28805 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28810 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28820 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28825 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28890 | PR ESWT HI AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 28899 | PR FOOT/TOES NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29000 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29010 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29015 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29020 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29025 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29035 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29040 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29044 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29046 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29049 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29055 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29058 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29065 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29075 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29085 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29086 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29105 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29125 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29126 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29130 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29131 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29200 | PR STRAPPING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29220 | PR STRAPPING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29240 | PR STRAPPING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29260 | PR STRAPPING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29280 | PR STRAPPING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29305 | PR APPLY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29325 | PR APPLY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29345 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29355 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29358 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29365 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29405 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29425 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29435 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29440 | PR ADDITION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29445 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29450 | PR APPLY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29505 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29515 | PR APPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29520 | PR STRAPPING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29530 | PR STRAPPING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29540 | PR STRAPPING; NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29550 | PR STRAPPING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29580 | PR APPLY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29581 | PR APPL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29582 | PR APPL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29583 | PR APPL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29584 | PR APPL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29700 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29705 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29710 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29715 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29720 | PR REPAIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29730 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29740 | PR WEDGING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29750 | PR WEDGING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29799 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29805 | PR SHLDR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29806 | PR SHLDR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29807 | PR SHLDR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29819 | PR SHLDR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29820 | PR SHLDR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29821 | PR SHLDR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29822 | PR SURGICAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29823 | PR SURGICAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29824 | PR SHLDR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29825 | PR SHLDR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29826 | PR SHOULDER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29827 | PR SHLDR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29828 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29830 | PR ELBOW NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29834 | PR ELBOW NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29835 | PR ELBOW NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29836 | PR ELBOW NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29837 | PR ELBOW NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29838 | PR ELBOW NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29840 | PR WRIST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29843 | PR WRIST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29844 | PR WRIST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29845 | PR WRIST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29846 | PR WRIST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29847 | PR WRIST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29848 | PR WRIST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29850 | PR KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29851 | PR KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29855 | PR TIBIAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29856 | PR TIBIAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29860 | PR HIP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29861 | PR HIP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29862 | PR HIP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29863 | PR HIP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29866 | PR KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29867 | PR KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29868 | PR KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29870 | PR KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29871 | PR KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29873 | PR KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29874 | PR KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29875 | PR KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29876 | PR KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29877 | PR KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29879 | PR KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29880 | PR ARTHRS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29881 | PR ARTHRS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29882 | PR KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29883 | PR KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29884 | PR KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29885 | PR KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29886 | PR KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29887 | PR KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29888 | PR KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29889 | PR KNEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29891 | PR ANKLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29892 | PR ANKLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29893 | PR ANKLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29894 | PR ANKLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29895 | PR ANKLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29897 | PR ANKLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29898 | PR ANKLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29899 | PR ANKLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29900 | PR ARTHROS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29901 | PR ARTHROS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29902 | PR ARTHROS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29904 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29905 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29906 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29907 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29914 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29915 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29916 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 29999 | PR UNLISTED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30100 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30120 | PR EXCISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30130 | PR EXCISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30140 | PR EXCISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30300 | PR REMOVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30310 | PR REMV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30320 | PR REMV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30400 | PR RECONSTR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30410 | PR RECONSTR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30420 | PR RECONSTR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30430 | PR REVIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30435 | PR REVIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30450 | PR REVIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30460 | PR REVIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30462 | PR REVIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30468 | PR RPR NSL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30469 | PR REPAIR OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30520 | PR REPAIR OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30580 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30620 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 3072F | LOW RISK FOR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30801 | PR CAUTER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30802 | PR CAUTER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30901 | PR CTRL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30903 | PR CTRL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30905 | PR CTRL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30906 | PR REPEAT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 30930 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31030 | PR EXPLOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31200 | PR REMOV AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31231 | PR NASAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31233 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31235 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31237 | PR NASAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31238 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31239 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31240 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31241 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31242 | DESTRUCTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31243 | DESTRUCTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31253 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31254 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31255 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31256 | PR NASAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31257 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31259 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31267 | PR NASAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31276 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31287 | PR NASAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31288 | PR NASAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31290 | PR NASAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31291 | PR NASAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31292 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31293 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31294 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31295 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31296 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31297 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31298 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31505 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31510 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31511 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31512 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31513 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31515 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31520 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31525 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31526 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31527 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31528 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31529 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31530 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31531 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31535 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31536 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31540 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31541 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31545 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31546 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31551 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31552 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31553 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31554 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31560 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31561 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31570 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31571 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31572 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31573 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31574 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31575 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31576 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31577 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31578 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31579 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31622 | PR BRNCHSC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31623 | PR BRNCHSC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 31624 | PR BRNCHSC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 32151 | PR THORCOM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 32408 | PR CORE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 32854 | PR LUNG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/6/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 33270 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 33271 | PR INSJ OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 33272 | PR RMVL OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 33273 | PR REPOS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 33274 | PR TCAT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 33370 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 33509 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 33741 | PR TAS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 33745 | PR TIS CRTJ ST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 33746 | PR TIS CRTJ ST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 33894 | PR EVASC ST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 33895 | PR EVASC ST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 33897 | PR PERQ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 33945 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/6/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 33995 | PR INSJ PERQ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 33997 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 36415 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 36430 | PR BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 36460 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 36468 | PR INJECTIONS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 36469 | PR INJECTION; AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 36470 | PR INJECTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 36471 | PR INJECTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 36473 | PR ENDOVEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 36474 | PR ENDOVEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 36475 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 36476 | PR ENDOVEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 36478 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 36479 | PR ENDOVEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 36589 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 36590 | PR RMVL TUN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 37197 | PR PRQ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 37700 | PR LIGATN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 37780 | PR LIGATN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 37785 | PR REVISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 38220 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 38221 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 38222 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 38241 | PR TRNSPLJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/6/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 38500 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 38505 | PR NEEDLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 38510 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 38520 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 38525 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 38530 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 38531 | PR OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 38542 | PR EXPLORE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 38550 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40490 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40500 | PR LIP SHAVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40510 | PR PARTIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40520 | PR PARTIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40525 | PR FULL THICK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40527 | PR FULL THICK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40530 | PR PARTIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40650 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40652 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40654 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40700 | PR REPAIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40701 | PR REPR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40702 | PR REPR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40761 | PR REPR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40799 | PR LIP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40800 | PR DRAIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40801 | PR DRAIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40804 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40805 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40806 | PR INCISION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40808 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40810 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40812 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40814 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40816 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40818 | PR EXCISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40819 | PR EXCISE LIP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40820 | PR DESTRUC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40830 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40831 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40840 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40842 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40843 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40844 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 40845 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41000 | PR I&D AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41005 | PR I&D AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41006 | PR I&D AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41007 | PR I&D AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41008 | PR I&D AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41009 | PR I&D AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41010 | PR INCISION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41015 | PR I&D AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41016 | PR I&D AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41017 | PR I&D AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41018 | PR I&D AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41100 | PR BIOPSY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41105 | PR BIOPSY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41108 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41110 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41112 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41113 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41114 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41115 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41116 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41120 | PR PART AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41130 | PR PART AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41135 | PR PART EXC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41140 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41145 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41150 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41153 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41155 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41510 | PR TONGUE TO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41520 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41599 | PR TONGUE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41800 | PR DRAINAGE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41805 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41806 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41820 | PR EXCISION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41821 | PR EXCISION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41822 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41823 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41825 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41826 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41827 | PR EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41828 | PR EXCISION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41830 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41850 | PR TREATMENT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41870 | PR GUM GRAFT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41872 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41874 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 41899 | PR DENTAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42100 | PR BIOPSY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42140 | PR EXCISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42200 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42205 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42210 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42215 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42220 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42225 | PR RECONST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42226 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42227 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42235 | PR REPAIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42260 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42300 | PR DRAIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42305 | PR DRAIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42400 | PR BIOPSY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42410 | PR EXC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42415 | PR EXC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42420 | PR EXC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42425 | PR EXC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42426 | PR EXC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42800 | PR BIOPSY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42809 | PR REMOVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42810 | PR EXCISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42815 | PR EXCISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42820 | REMOVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42821 | PR REMOVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42825 | REMOVAL OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42826 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42830 | REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42831 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42835 | REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42836 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 42975 | PR DISE DYN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43180 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43191 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43192 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43193 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43194 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43195 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43196 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43197 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43198 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43200 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43201 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43202 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43204 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43205 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43206 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43210 | PR EGD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43211 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43212 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43213 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43214 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43215 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43216 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43217 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43219 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43220 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43226 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43227 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43228 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43229 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43231 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43232 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43233 | PR EGD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43234 | PR UPPER GI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43235 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43236 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43237 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43238 | PR EGD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43239 | PR EGD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43240 | PR EGD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43241 | PR EGD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43242 | PR EGD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43243 | PR EGD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43244 | PR EGD BAND NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43245 | PR EGD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43246 | PR EGD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43247 | PR EGD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43248 | PR EGD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43249 | PR EGD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43250 | PR EGD FLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43251 | PR EGD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43252 | PR EGD FLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43253 | PR EGD US NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43254 | PR EGD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43255 | PR EGD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43256 | PR UPPER GI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43257 | PR EGD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43258 | PR UPPER GI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43259 | PR EDG US NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43260 | PR ERCP DX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43261 | PR ERCP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43262 | PR ERCP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43263 | PR ERCP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43264 | PR ERCP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43265 | PR ERCP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43266 | PR EGD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43267 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43268 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43269 | PR ERCP,RMV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43270 | PR EGD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43271 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43272 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43273 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43274 | PR ERCP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43275 | PR ERCP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43276 | PR ERCP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43277 | PR ERCP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43278 | PR ERCP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43644 | PR LAP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43645 | PR LAP GASTR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43653 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43770 | LAP, PLACE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43775 | LONGITUDINAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43842 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43843 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43845 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43846 | PR GASTRIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43847 | PR GASTRIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 43848 | REVISION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 44100 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 44388 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 44389 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 44390 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 44391 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 44392 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 44393 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 44394 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 44397 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 44401 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 44402 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 44403 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 44404 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 44405 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 44406 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 44407 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 44408 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45000 | PR DRAINAGE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45005 | PR I&D RECTAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45020 | PR DRAINAGE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45100 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45330 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45378 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45379 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45380 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45381 | PR COLSC FLX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45382 | PR COLSC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45383 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45384 | PR COLSC FLX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45385 | PR COLSC FLX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45386 | PR COLSC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45387 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45388 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45389 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45390 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45391 | PR COLSC FLX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45392 | PR COLSC FLX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45393 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45395 | PR LAP, SURG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45397 | PR LAP, SURG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 45398 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 46040 | PR I&D AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 46045 | PR I&D RECTAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 46050 | PR I&D AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 46060 | PR I&D RECTAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 46600 | PR ANOSCOPY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 46910 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 46916 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 46917 | PR LASER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 46922 | PR SURG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 46924 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 47000 | PR BIOPSY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 47001 | PR NEEDLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 47100 | PR WEDGE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 47135 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/6/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 47562 | PR AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 47563 | PR AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 47564 | PR AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 47570 | PR AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 47579 | PR LAP,BILIARY AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 47600 | PR REMOVAL AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 47605 | PR REMV AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 47610 | PR REMV AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 47612 | PR REMV GB,W AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 47620 | PR REMV GB,W AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 48100 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49180 | PR PERCUT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49402 | PR REMOVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49452 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49491 | REPAIR ING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49492 | REPAIR ING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49495 | REPAIR ING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49496 | REPAIR ING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49500 | REPAIR ING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49501 | PR REPAIR ING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49505 | PR REPAIR ING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49507 | PR REPAIR ING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49520 | PR REPAIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49521 | PR REPAIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49525 | PR REPAIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49591 | PR REPAIR OF NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Umbilical CLINICAL INFORMATION C, S, SK CP 5/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49592 | PR REPAIR OF AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49593 | PR REPAIR OF NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Umbilical CLINICAL INFORMATION C, S, SK CP 5/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49594 | PR REPAIR OF AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49595 | PR REPAIR OF NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Umbilical CLINICAL INFORMATION C, S, SK CP 5/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49596 | PR REPAIR OF AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49613 | PR REPAIR OF NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Umbilical CLINICAL INFORMATION C, S, SK CP 5/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49614 | PR REPAIR OF AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49615 | PR REPAIR OF NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Umbilical CLINICAL INFORMATION C, S, SK CP 5/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49616 | PR REPAIR OF AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49617 | PR REPAIR OF NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Umbilical CLINICAL INFORMATION C, S, SK CP 5/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49618 | PR REPAIR OF AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49650 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 49651 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 50200 | PR RENAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 50205 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 50360 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/6/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 50365 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/6/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 50590 | PR FRAGMENT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 51600 | ( , , , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 51605 | ( , , , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 51610 | ( , , , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 51701 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 51725 | PR SIMPLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 51726 | PR COMPLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 51727 | PR COMPLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 51728 | CYSTOMETRO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 51729 | PR COMPLX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 51736 | PR URINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 51741 | PR ELECTRO- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 51784 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 51785 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 51792 | PR URINARY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 51797 | VOIDING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 51798 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52000 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52001 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52005 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52007 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52010 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52204 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52214 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52224 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52234 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52235 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52240 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52250 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52260 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52265 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52270 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52275 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52276 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52277 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52281 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52282 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52283 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52284 | CYSTO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52285 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52287 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52290 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52300 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52301 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52305 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52310 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52315 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52317 | PR REMOVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52318 | PR REMOVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52320 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52325 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52327 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52330 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52332 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52334 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52341 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52342 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52343 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52344 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52345 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52346 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52351 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52352 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52353 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52354 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52355 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52356 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52441 | PR CYSTO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52442 | PR CYSTO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52601 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52630 | PR REMV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52640 | PR RELIEVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 52649 | PR LASER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 53020 | PR INCISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 53200 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 53400 | PR REVISE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 53405 | PR REVISE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 53410 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 53415 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 53420 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 53425 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 53430 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 53431 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 53440 | PR SLING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 53442 | PR REVISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 53444 | PR INSERTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 53445 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 53446 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 53447 | PR REMOVAL & NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 53850 | PR PROSTATIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 53852 | PR PROSTATIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 53854 | PR TRURL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 53855 | PR INSERT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54050 | PR DESTR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54055 | PR DESTR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54056 | PR DESTR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54060 | PR DESTR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54065 | PR DESTR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54100 | PR BX,PENIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54105 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54110 | PR EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54111 | PR EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54112 | PR EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54115 | PR REMV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54120 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54125 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54130 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54135 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54150 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54160 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54161 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54162 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54163 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54164 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54300 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54304 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54312 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54316 | PR HYPOSPAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54318 | PR HYPOSPAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54322 | PR HYPOSPAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54324 | PR HYPOSPAD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54326 | PR HYPOSPAD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54328 | PR HYPOSPAD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54332 | PR HYPOSPAD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54336 | PR HYPOSPAD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54340 | PR RPR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54344 | PR RPR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54348 | PR RPR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54352 | PR REVISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54360 | PR PENIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54380 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54385 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54390 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54406 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54415 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54420 | PR CORPORA- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54430 | PR CORPORA AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54435 | PR CORPORA- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54437 | PR REPAIR OF AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54438 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54440 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54500 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54505 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54530 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54550 | PR EXPLORE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54600 | PR REDUCE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54620 | PR FIXATN OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54640 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54650 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54660 | PR INSERT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54670 | PR REPAIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54680 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54690 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54692 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 54800 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 55250 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 55700 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 55705 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 55706 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 55867 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 55970 | PR SEX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 12/30/2020 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 55980 | PR SEX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 12/30/2020 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 56405 | PR I&D OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 56420 | PR I&D AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 56440 | PR MARSUP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 56501 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 56515 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 56605 | PR BIOPSY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 56606 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 56800 | PR REPAIR OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 56805 | PR REPAIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 56810 | PR REPAIR OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57100 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57105 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57156 | PR INSERT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57291 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57292 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57335 | PR REVISE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57415 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57452 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57454 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57455 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57456 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57460 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57461 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57500 | PR BIOPSY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57505 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57510 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57511 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57513 | PR LASER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57520 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57522 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57530 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57531 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57540 | PR REMV CERV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57545 | PR REMV CERV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57550 | PR REMV CERV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57555 | PR REMV CERV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57556 | PR REMV CERV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57558 | PR D&C OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57700 | PR REVISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57720 | PR PLASTIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57800 | PR DILATION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 57820 | PR D&C OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58100 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58150 | PR TOTAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58152 | PR TOTAL ABD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58180 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58200 | PR TOTAL ABD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58210 | PR RADICAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58240 | PR PELVIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58260 | PR VAGINAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58262 | PR VAG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58263 | PR VAG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58267 | PR VAG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58270 | PR VAG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58275 | PR VAG HYST, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58280 | PR VAG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58285 | PR VAG HYST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58290 | PR VAG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58291 | PR VAG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58292 | PR VAG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58294 | PR VAG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58300 | PR INSERT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK C, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58301 | PR REMOVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK C, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58340 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58555 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58558 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58559 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58560 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58561 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58562 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58563 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58565 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK C, CP 5/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58570 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58571 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58572 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58573 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58600 | PR LIGATE NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (BILATERAL CLINICAL INFORMATION S, SK C, CP 5/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58605 | PR LIGATE NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (BILATERAL CLINICAL INFORMATION S, SK C, CP 5/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58611 | PR NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (BILATERAL CLINICAL INFORMATION S, SK C, CP 5/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58615 | PR OCCLUDE NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (BILATERAL CLINICAL INFORMATION S, SK C, CP 5/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58661 | PR LAP,RMV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK C, CP 8/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58670 | PR LAP,TUBAL NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (BILATERAL CLINICAL INFORMATION S, SK C, CP 5/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58671 | PR LAP,TUBAL NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (BILATERAL CLINICAL INFORMATION S, SK C, CP 5/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58700 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK C, CP 8/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 58900 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59000 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59001 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59012 | PR FETAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59025 | PR FETAL NON- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59120 | PR TREAT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 9/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59121 | PR TREAT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 9/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59150 | PR RX ECTOP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 9/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59151 | PR RX ECTOP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 9/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59160 | PR D&C AFTER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59320 | PR REVISION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59325 | PR REVISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59400 | PR FULL ROUT NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59409 | PR AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59410 | PR OBSTE NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59430 | PR CARE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59510 | PR FULL ROUT NO AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59514 | PR CESAREAN NO AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59515 | PR CESAREAN AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59610 | PR ROUT OB AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59612 | PR VAG DELIV AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59614 | PR VAG DELIV AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59618 | PR ROUT OB NO AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59620 | PR C-SEC NO AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59622 | PR C-SEC NO AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59812 | PR SURG RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59820 | PR SURG RX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59821 | PR SURG RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59830 | PR SURG RX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59840 | PR INDUCED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK C, CP 8/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59841 | PR INDUCED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK C, CP 8/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59850 | PR INDUCED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK C, CP 8/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59851 | PR INDUCED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK C, CP 8/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59852 | PR INDUCED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK C, CP 8/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59855 | PR INDUCED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK C, CP 8/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59870 | PR EVACUATE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 59871 | PR REMOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 60100 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 61570 | PR REMOVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 61736 | PR LITT LES AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 61737 | PR LITT LES AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 61782 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 62322 | PR NJX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 63052 | PR LAM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 63053 | PR LAM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64445 | PR INJECTION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64446 | PR INJECTION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64447 | PR INJECTION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64470 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64472 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64475 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64476 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64479 | PR NJX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64480 | PR NJX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64483 | PR NJX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64484 | PR NJX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64486 | PR TAP BLOCK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64487 | PR TAP BLOCK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64488 | PR TAP BLOCK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64489 | PR TAP BLOCK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64490 | PR NJX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64491 | PR NJX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64492 | PR NJX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64493 | PR NJX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64494 | PR NJX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64495 | PR NJX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64510 | PR INJECT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64582 | PR OPEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64583 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64584 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64628 | PR THERMAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64716 | PR REVISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64732 | PR TRANSECT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64734 | PR TRANSECT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64736 | PR TRANSECT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64738 | PR TRANSECT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64740 | PR TRANSECT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64742 | PR TRANSECT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64864 | PR REPR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64865 | PR REPR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64866 | PR ANAST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64868 | PR ANAST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 64870 | PR ANAST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65091 | PR REMOVE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65093 | PR REMOVE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65101 | PR REMOVAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65103 | PR REMOVE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65105 | PR REMOVE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65110 | PR REMOVAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65112 | PR REMOVE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65114 | PR REMOVE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65125 | PR MODIFY AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65130 | PR LATE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65135 | PR LATE OCUL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65140 | PR LATE OCUL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65150 | PR REINSERT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65155 | PR REINSERT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65175 | PR REMOVAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65205 | PR REMV AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65210 | PR REMV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65220 | PR REMV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65222 | PR REMV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65235 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65260 | PR REMV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65265 | PR REMV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65270 | PR REPAIR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65272 | PR REPAIR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65273 | PR REPAIR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65275 | PR REPAIR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65280 | PR REPAIR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65285 | PR REPAIR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65286 | PR REPAIR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65290 | PR REPAIR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65400 | PR EXCIS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65410 | PR BIOPSY OF AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65420 | PR EXCIS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65426 | PR EXCIS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65430 | PR CORNEAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65435 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65436 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65450 | PR DESTR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65600 | PR MULT PUNC AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65710 | PR CORNEAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65730 | PR CORNEAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65750 | PR CORNEAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65755 | PR CORNEAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65756 | PR CORNEAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65757 | PR PREP AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65760 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65765 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65767 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65770 | PR REVISE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65771 | PR RADIAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65772 | PR CORNEAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65775 | PR CORNEAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65778 | PR PLACE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65779 | PR PLACE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65780 | PR OCULAR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65781 | PR OCULAR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65782 | PR OCULAR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65785 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65800 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65810 | PR DRAIN ANT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65815 | PR DRAIN ANT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65820 | PR RELIEVE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65850 | PR INCISION AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65855 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65860 | PR INCISE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65865 | PR INCISE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65870 | PR INCISE ANT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65875 | PR INCISE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65880 | PR INCISE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65900 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65920 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 65930 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66020 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66030 | PR INJECT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66130 | PR REMOVE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66150 | PR GLAUCOMA AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66155 | PR GLAUCOMA AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66160 | PR GLAUCOMA AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66170 | PR GLAUCOMA AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66172 | PR GLAUCOMA AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66174 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66175 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66179 | PR AQUEOUS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66180 | PR AQUEOUS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66183 | PR INSERT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66184 | PR REVJ AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66185 | PR REVJ AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66225 | PR REPAIR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66250 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66500 | PR INCISION AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66505 | PR INCISION AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66600 | PR REMV AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66605 | PR REMV AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66625 | PR REMV AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66630 | PR REMV AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66635 | PR REMV AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66680 | PR REPAIR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66682 | PR SUTURE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66700 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66710 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66711 | PR ECP AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66720 | PR CILIARY AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66740 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66761 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66762 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66770 | PR RESEC AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66820 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66821 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66825 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66830 | PR REMV 2ND AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66840 | PR REMV LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66850 | PR REMV LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66852 | PR REMV LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66920 | PR EXTRACT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66930 | PR EXTRACT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66940 | PR EXTRACT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66982 | PR XCAPSL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66983 | PR REMV AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66984 | PR XCAPSL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66985 | PR INSERT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66986 | PR EXCHANGE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66987 | PR XCAPSL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66988 | PR XCAPSL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66989 | PR XCAPSL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66990 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66991 | PR XCAPSL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 66999 | PR EYE SURG AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67005 | PR PART REMV AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67010 | PR SUBTOT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67015 | PR RELEAS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67025 | PR REPLACE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67027 | PR IMPLANT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67028 | PR INJECT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67030 | PR INCISE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67031 | PR LASER AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67036 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67039 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67040 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67041 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67042 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67043 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67101 | PR RPR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67105 | PR RPR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67107 | PR REPAIR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67108 | PR RPR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67110 | PR REPAIR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67113 | PR RPR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67115 | PR RELEASE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67120 | PR REMV POST AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67121 | PR REMV POST AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67141 | PR PROPH AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67145 | PR PROPH AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67208 | PR DESTRUC AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67210 | PR DESTRUC AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67218 | PR DESTRUC AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67220 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67221 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67225 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67227 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67228 | PR TREATMENT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67229 | PR TX AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67250 | PR REINFORCE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67255 | PR REINFORCE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67299 | PR EYE SURG AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67311 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67312 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67314 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67316 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67318 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67320 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67331 | PR STRABISM AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67332 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67334 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67335 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67340 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67343 | PR RELEASE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67345 | PR DESTROY AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67346 | PR BIOPSY OF AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67399 | PR UNLISTED AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67400 | PR EXPLORE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67405 | PR EXPLORE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67412 | PR EXPLORE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67413 | PR EXPLORE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67414 | PR EXPLORE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67415 | PR NEEDLE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67420 | PR LAT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67430 | PR LAT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67440 | PR LAT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67445 | PR LAT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67450 | PR LAT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67500 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67505 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67515 | PR INJ,THER AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67550 | PR INSERT EYE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67560 | PR REVISE EYE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67570 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67599 | PR ORBIT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67700 | PR DRAINAGE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67710 | PR INCISION AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67715 | PR INCISION AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67800 | PR EXCIS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67801 | PR EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67805 | PR EXCIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67808 | PR EXCIS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67810 | PR INCISIONAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67820 | PR REVISE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67825 | PR REVISE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67830 | PR REVISE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67835 | PR REVISE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67840 | PR REMOVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67850 | PR DESTRUC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67875 | PR TEMP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67880 | PR REVISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67882 | PR REVISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67900 | PR REPAIR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67901 | PR FIX LID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67902 | PR FIX LID AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67903 | PR FIX LID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67904 | PR FIX LID AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67906 | PR FIX LID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67908 | PR FIX LID AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67909 | PR REDN AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67911 | PR CORRECT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67912 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67914 | PR FIX AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67915 | PR FIX AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67916 | PR FIX AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67917 | PR FIX AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67921 | PR FIX AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67922 | PR FIX AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67923 | PR FIX AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67924 | PR FIX AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67930 | PR SUTURE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67935 | PR SUTURE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67938 | PR REMOVE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67950 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67961 | PR REVISION AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67966 | PR REVISION AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67971 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67973 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67974 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67975 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 67999 | PR REVISION AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68020 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68040 | PR EXPRESS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68100 | PR BIOPSY OF AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68110 | PR EXCIS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68115 | PR EXCIS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68130 | PR EXCIS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68135 | PR DESTRUC AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68200 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68320 | PR REVISE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68325 | PR REVISE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68326 | PR REVISE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68328 | PR REVISE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68330 | PR REPAIR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68335 | PR REPAIR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68340 | PR DIVISION OF AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68360 | PR CONJUNC AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68362 | PR CONJUNC AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68371 | PR HARVEST AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68399 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68400 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68420 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68440 | PR INCISE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68500 | PR REMOVAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68505 | PR REMOVAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68510 | PR BIOPSY OF AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68520 | PR REMOVAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68525 | PR BIOPSY OF AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68530 | PR REMV AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68540 | PR REMV TEAR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68550 | PR REMV TEAR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68700 | PR REPAIR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68705 | PR REVISE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68720 | PR CREATE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68745 | PR CREATE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68760 | PR CLOSE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68761 | PR CLOSE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68770 | PR CLOSE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68801 | PR DILATION AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68810 | PR PROBE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68811 | PR PROBE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68815 | PR PROBE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68816 | PR PROBE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68840 | PR EXPLORE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68850 | PR INJECTION AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 68899 | PR TEAR DUCT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69090 | PR PIERCE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69100 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69105 | PR BIOPSY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69110 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69120 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69140 | PR REMV EXT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69145 | PR REMV EXT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69150 | PR RAD EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69155 | PR RAD EXCIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69200 | PR REMV EXT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69205 | PR REMV EXT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69209 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69210 | PR REMOVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69300 | PR OTOPLASTY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69420 | PR INCISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69421 | PR INCISION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69424 | PR VENT TUBE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69433 | PR CREATE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69436 | PR CREATE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69440 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69450 | PR EARDRUM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69610 | PR REPAIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69620 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69631 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69632 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69633 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69635 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69636 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69637 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69641 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69642 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69643 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69644 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69645 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69646 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69705 | PR SURG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69706 | PR SURG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69710 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69711 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69714 | PR IMPLTJ OI AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69716 | PR IMPLTJ OI AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69719 | PR RPLCMT OI AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69726 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69727 | PR REMOVAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69728 | PR REMOVAL, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69729 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69730 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69799 | PR MIDDLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69930 | PR IMPLANT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 69955 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70010 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70015 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70030 | PR X-RAY EYE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70100 | PR X-RAY JAW NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70110 | PR X-RAY JAW NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70120 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70130 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70134 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70140 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70150 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70160 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70170 | PR X-RAY TEAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70190 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70200 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70210 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70220 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70240 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70250 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70260 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70300 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70310 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70320 | PR FULL NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70328 | PR X-RAY TMJ NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70330 | PR X-RAY TMJ NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70332 | PR X-RAY TMJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70336 | PR MRI, TMJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70350 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70355 | PR NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70360 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70370 | PR THROAT X- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70371 | EVALUATION ( ), VCUG | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70380 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70390 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70450 | PR CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70460 | PR CT SCAN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70470 | PR CT SCAN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70480 | PR CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70481 | PR CT SCAN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70482 | PR CT SCAN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70486 | PR CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70487 | PR CT SCAN, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70488 | PR CT SCANS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70490 | PR CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70491 | PR CT NECK NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70492 | PR CT NECK NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70496 | PR CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70498 | PR CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70540 | PR MRI, FACE, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70542 | PR MRI, FACE, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70543 | PR MRI, FACE, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70544 | PR MR ANGIO, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70545 | PR MR ANGIO, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70546 | PR MR ANGIO, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70547 | PR MR ANGIO, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70548 | PR MR ANGIO, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70549 | PR MR ANGIO, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70551 | PR MRI BRAIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70552 | PR MRI BRAIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70553 | PR MRI BRAIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70554 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70555 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70557 | PR MRI BRAIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70558 | PR MRI BRAIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 70559 | PR MRI BRAIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 71045 | CHG NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 71046 | CHG NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 71047 | CHG NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 71048 | CHG NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 71100 | PR X-RAY RIBS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 71101 | PR X-RAY RIBS, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 71110 | PR X-RAY RIBS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 71111 | PR X-RAY RIBS, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 71120 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 71130 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 71250 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 71260 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 71270 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 71271 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 71275 | PR CT ANGIO, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 71550 | PR MRI, CHEST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 71551 | PR MRI, CHEST, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 71552 | PR MRI, CHEST, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 71555 | PR MR ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72020 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72040 | CHG RADEX NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72050 | CHG RADEX NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72052 | CHG RADEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72070 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72072 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72074 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72080 | CHG RADEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72081 | CHG RADEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72082 | CHG RADEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72083 | CHG RADEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72084 | CHG RADEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72100 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72110 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72114 | PR RADEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72120 | PR RADEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72125 | PR CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72126 | PR CT SCAN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72127 | PR CT SCAN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72128 | PR CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72129 | PR CT SCAN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72130 | PR CT SCAN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72131 | PR CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72132 | PR CT SCAN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72133 | PR CT SCAN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72141 | PR MRI, CERV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72142 | PR MRI, CERV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72146 | PR MRI, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72147 | PR MRI, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72148 | PR MRI, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72149 | PR MRI, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72156 | PR MRI, CERV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72157 | PR MRI, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72158 | PR MRI, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72159 | PR MR ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72170 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72190 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72191 | PR CT ANGIO, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72192 | PR CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72193 | PR CT SCAN OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72194 | PR CT SCAN OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72195 | PR MRI, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72196 | PR MRI, PELVIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72197 | PR MRI, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72198 | PR MR ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72200 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72202 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72220 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72240 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72255 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72265 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72270 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72285 | PR X- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 72295 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73000 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73010 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73020 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73030 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73040 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73050 | PR X-RAY AC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73060 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73070 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73080 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73085 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73090 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73092 | PR X-RAY ARM, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73100 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73110 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73115 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73120 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73130 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73140 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73200 | PR CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73201 | PR CT SCAN OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73202 | PR CT SCAN OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73206 | PR CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73218 | PR MRI, UPPER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73219 | PR MRI, UPPER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73220 | PR MRI UPPER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73221 | PR MRI, JOINT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73222 | PR MRI, JOINT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73223 | PR MRI, JOINT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73225 | PR MR ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73501 | CHG RADEX NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73502 | CHG RADEX NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73503 | CHG RADEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73521 | CHG RADEX NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73522 | CHG RADEX NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73523 | CHG RADEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73525 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73551 | CHG NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73552 | CHG NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73560 | PR X-RAY KNEE NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73562 | PR X-RAY KNEE NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73564 | PR X-RAY KNEE NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73565 | PR X-RAY KNEE NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73580 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73590 | PR X-RAY TIB + NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73592 | PR X-RAY LEG, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73600 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73610 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73615 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73620 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73630 | PR X-RAY NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73650 | PR X-RAY HEEL NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73660 | PR X-RAY TOE NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73700 | PR CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73701 | PR CT SCAN OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73702 | PR CT SCAN OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73706 | PR CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73718 | PR MRI, LOWER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73719 | PR MRI, LOWER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73720 | PR MRI, LOWER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73721 | PR MRI LOWER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73722 | PR MRI, JOINT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73723 | PR MRI, JOINT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 73725 | PR MR ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74018 | CHG NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74019 | CHG NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74021 | CHG NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74022 | CHG NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Mobile X Ray CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74150 | PR CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74160 | PR CT SCAN OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74170 | PR CT SCAN OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74174 | PR CT ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74175 | PR CT ANGIO, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74176 | CHG CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74177 | CHG CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74178 | CHG CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74181 | PR MRI, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74182 | PR MRI, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74183 | PR MRI, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74185 | PR MR ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74190 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74210 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74220 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74221 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74230 | ), SPEECH | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74235 | PR REMOVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74240 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74246 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74248 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74250 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74251 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74261 | CHG CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74262 | CHG CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74263 | CHG CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74270 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74280 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74283 | PR X-RAY B.E. NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74290 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74300 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74301 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74328 | PR X-RAY FOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74329 | PR X-RAY FOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74330 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74340 | CHG INTRO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74355 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74360 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74363 | PR PERCUT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74400 | PR X-RAY IV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74410 | PR X-RAY IV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74415 | PR X-RAY IV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74420 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74425 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74430 | X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74440 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74445 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74450 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74455 | ( , , , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74470 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74485 | CHG DILATION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74710 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74712 | CHG FETAL MRI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74713 | CHG FETAL MRI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74740 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 74775 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75557 | CHG CARDIAC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75559 | CHG CARDIAC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75561 | CHG CARDIAC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75563 | CHG CARDIAC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75565 | CARD MRI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75571 | PR UNDER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75572 | PR CT HRT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75573 | CHG CT HEART NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75574 | PR CT ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75580 | N-INVAS EST C NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75600 | PR ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75605 | PR ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75625 | PR ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75630 | PR ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75635 | PR CT ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75705 | PR ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75710 | PR ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75716 | PR ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75726 | PR ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75731 | PR ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75733 | PR ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75736 | PR ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75741 | PR ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75743 | PR ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75746 | PR ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75756 | PR ANGIO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75774 | PR ANGIO EA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75801 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75803 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75805 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75807 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75809 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75810 | PR VENOGRAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75820 | PR VENOGRAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75822 | PR VENOGRAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75825 | PR VENOGRAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75827 | PR VENOGRAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75831 | PR VENOGRAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75833 | PR VENOGRAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75840 | PR VENOGRAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75842 | PR VENOGRAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75860 | PR VENOGRAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75870 | PR VENOGRAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75872 | PR VENOGRAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75880 | PR VENOGRAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75885 | PR PERCUT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75887 | PR PERCUT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75889 | PR VENOGRAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75891 | PR VENOGRAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75893 | PR VENOUS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75894 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75898 | CHG ANGRPH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75901 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75902 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75956 | PR ENDOVASC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75957 | PR ENDOVASC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75958 | PR PROXIMAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75959 | PR DELAYED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75970 | PR VASCULAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75984 | CHANGE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 75989 | PR RAD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76000 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76010 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76080 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76098 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76100 | PR X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76120 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76125 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76145 | CHG MEDICAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76376 | CHG 3D NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76377 | CHG 3D NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76380 | PR CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76390 | PR MRI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76391 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76496 | CHG UNLISTED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76497 | PR UNLISTED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76498 | PR UNLISTED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76499 | CHG UNLISTED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76506 | US, HEAD, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76510 | US, EYE, B- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76511 | US, EYE A- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76512 | US, EYE B- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76513 | CHG DX AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76514 | US, EYE, FOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76516 | US, EYE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76519 | US, EYE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76529 | US, EYE F.B. NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76536 | US, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76700 | US, ABDOM,B- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76705 | US, ABDOMEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76706 | CHG US NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76770 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76775 | US, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76800 | US, SPINAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76801 | US, OB < 14 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76802 | US, OB < 14 NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76805 | US, OB >/= 14 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76810 | US, OB >/= 14 NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76811 | PR US,PREG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76812 | PR US,PREG NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76813 | CHG US FETAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76814 | CHG US FETAL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76815 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76816 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76817 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76818 | PR FETAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76819 | PR FETAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76820 | CHG US NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76821 | CHG US AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76825 | PR SONO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76827 | PR SONO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76830 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76831 | PR SONO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76856 | PR US,PELVIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76857 | PR US,PELVIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76870 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76872 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76873 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76881 | CHG US COMPL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76882 | CHG US LMTD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76883 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76885 | CHG US INFT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76886 | CHG US INFT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76932 | PR SONO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76936 | PR US NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76937 | PR US GUIDE, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76940 | PR US GUIDE, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76941 | PR SONO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76942 | PR SONO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76945 | PR SONO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76946 | PR SONO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76948 | PR SONO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76965 | PR SONO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76975 | PR GI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76977 | PR SONO BONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76978 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76979 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76981 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76982 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76983 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76998 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 76999 | UNLISTED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77012 | PR CT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77046 | CHG MRI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77047 | CHG MRI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77048 | CHG MRI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77049 | CHG MRI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77053 | PR MAMMARY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77054 | PR MAMMARY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77065 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77066 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77067 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77072 | PR X-RAYS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77078 | PR CT BONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77080 | PR DEXA,BONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77081 | PR DEXA,BONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77084 | PR MRI, BONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77085 | CHG DXA BONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77086 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77261 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77262 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77263 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77280 | CHG SET RADN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77285 | CHG SET RADN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77290 | CHG SET RADN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77293 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77295 | CHG 3-D NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77299 | CHG RADN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77300 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77301 | CHG INTEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77305 | CHG TELETHER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77306 | CHG TELETHX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77307 | CHG TELETHX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77310 | CHG TELETHER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77315 | CHG TELETHER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77316 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77317 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77318 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77321 | CHG TELETHER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77326 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77327 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77328 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77331 | CHG SPECIAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77332 | CHG RADN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77333 | CHG RADN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77334 | CHG RADN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77336 | CHG RADN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77338 | CHG MLC IMRT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77370 | CHG RADN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77371 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77372 | RADIATION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77373 | PR RADN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77385 | CHG INTENSITY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77386 | CHG INTENSITY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77387 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77399 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77401 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77402 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77403 | CHG RADN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77404 | CHG RADN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77406 | CHG RADN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77407 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77408 | CHG RADN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77409 | CHG RADN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77411 | CHG RADN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77412 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77413 | CHG RADN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77414 | CHG RADN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77416 | CHG RADN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77417 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77418 | CHG INTEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77421 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77423 | PR NEUTRON NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77424 | PR INTRAOP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77425 | PR INTRAOP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77427 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77431 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77432 | STEREOTACTIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77435 | PR RADN RX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77469 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77470 | PR SPECIAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77499 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77520 | CHG PROTON NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77525 | CHG PROTON NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77750 | CHG INFUSE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77761 | CHG INTRACAV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77762 | CHG INTRACAV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77763 | CHG INTRACAV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77767 | CHG HDR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77768 | CHG HDR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77770 | CHG HDR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77771 | CHG HDR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77772 | CHG HDR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77778 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77786 | CHG REMOTE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77789 | CHG SURFACE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77790 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 77799 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78012 | CHG THYROID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78013 | CHG THYROID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78014 | CHG THYROID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78015 | PR THYROID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78016 | PR THYROID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78018 | PR THYROID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78020 | PR THYROID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78070 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78071 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78072 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78075 | PR ADRENAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78099 | PR ENDOCRINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78102 | PR BONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78103 | PR BONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78104 | PR BONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78110 | PR PLASMA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78111 | PR PLASMA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78120 | PR RED CELL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78121 | PR RED CELL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78122 | PR BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78130 | CHG RED CELL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78140 | PR RED CELL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78185 | PR SPLEEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78191 | PR PLATELET NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78195 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78199 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78201 | PR LIVER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78202 | PR LIVER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78215 | PR LIVER AND NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78216 | PR LIVER & NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78226 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78227 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78230 | PR SALIVARY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78231 | PR SERIAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78232 | PR SALIVARY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78258 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78261 | PR GASTRIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78262 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78264 | CHG GASTRIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78267 | PR BREATH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78268 | PR BREATH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78278 | PR ACUTE GI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78282 | PR GI PROTEIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78290 | PR BOWEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78291 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78299 | PR GI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78300 | PR BONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78305 | PR BONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78306 | PR BONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78315 | PR BONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78320 | PR BONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78350 | PR BONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78399 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78414 | PR NON- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78428 | PR CARDIAC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78429 | CHG MYOCRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78430 | CHG MYOCRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78431 | CHG MYOCRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78432 | CHG MYOCRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78433 | CHG MYOCRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78434 | CHG AQMBF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78445 | PR VASCULAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78451 | HT MUSCLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78452 | HT MUSCLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78453 | HEART NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78454 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78455 | CHG VENOUS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78456 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78457 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78458 | PR VEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78459 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78460 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78461 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78462 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78463 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78464 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78465 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78466 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78467 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78468 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78469 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78470 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78471 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78472 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78473 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78474 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78475 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78476 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78477 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78478 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78479 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78480 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78481 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78482 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78483 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78484 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78485 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78486 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78487 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78488 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78489 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78490 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78491 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78492 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78493 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78494 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78495 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78496 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78497 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78498 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78499 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78500 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78501 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78502 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78503 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78504 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78505 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78506 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78507 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78508 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78509 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78510 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78511 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78512 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78513 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78514 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78515 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78516 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78517 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78518 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78519 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78520 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78521 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78522 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78523 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78524 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78525 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78526 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78527 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78528 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78529 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78530 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78531 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78532 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78533 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78534 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78535 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78536 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78537 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78538 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78539 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78540 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78541 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78542 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78543 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78544 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78545 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78546 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78547 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78548 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78549 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78550 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78551 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78552 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78553 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78554 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78555 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78556 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78557 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78558 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78559 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78560 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78561 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78562 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78563 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78564 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78565 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78566 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78567 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78568 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78569 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78570 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78571 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78572 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78573 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78574 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78575 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78576 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78577 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78578 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78579 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78580 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78581 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78582 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78583 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78584 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78585 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78586 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78587 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78588 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78589 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78590 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78591 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78592 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78593 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78594 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78595 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78596 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78597 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78598 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78599 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78600 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78601 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78602 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78603 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78604 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78605 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78606 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78607 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78608 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78609 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78610 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78611 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78612 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78613 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78614 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78615 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78616 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78617 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78618 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78619 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78620 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78621 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78622 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78623 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78624 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78625 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78626 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78627 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78628 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78629 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78630 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78631 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78632 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78633 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78634 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78635 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78636 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78637 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78638 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78639 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78640 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78641 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78642 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78643 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78644 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78645 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78646 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78647 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78648 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78649 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78650 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78651 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78652 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78653 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78654 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78655 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78656 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78657 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78658 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78659 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78660 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78661 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78662 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78663 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78664 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78665 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78666 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78667 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78668 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78669 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78670 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78671 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78672 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78673 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78674 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78675 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78676 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78677 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78678 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78679 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78680 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78681 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78682 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78683 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78684 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78685 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78686 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78687 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78688 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78689 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78690 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78691 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78692 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78693 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78694 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78695 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78696 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78697 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78698 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78699 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78700 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78701 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78702 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78703 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78704 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78705 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78706 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78707 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78708 | PR RENAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78709 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78710 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78711 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78712 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78713 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78714 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78715 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78716 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78717 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78718 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78719 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78720 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78721 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78722 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78723 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78724 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78725 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78726 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78727 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78728 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78729 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78730 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78731 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78732 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78733 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78734 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78735 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78736 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78737 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78738 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78739 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78740 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78741 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78742 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78743 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78744 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78745 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78746 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78747 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78748 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78749 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78750 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78751 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78752 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78753 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78754 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78755 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78756 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78757 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78758 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78759 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78760 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78761 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78762 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78763 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78764 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78765 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78766 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78767 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78768 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78769 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78770 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78771 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78772 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78773 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78774 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78775 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78776 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78777 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78778 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78779 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78780 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78781 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78782 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78783 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78784 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78785 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78786 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78787 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78788 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78789 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78790 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78791 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78792 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78793 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78794 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78795 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78796 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78797 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78798 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78799 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78800 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78801 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78802 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78803 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78804 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78805 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78806 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78807 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78808 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78809 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78810 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78811 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78812 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78813 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78814 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78815 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78816 | SCAN( , ) | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 78999 | CHG NUCLEAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 79005 | CHG NUC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 79101 | CHG NUC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 79200 | PR NUCLEAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 79300 | PR NUCLEAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 79403 | PR NUCLEAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 79440 | PR NUCLEAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 79445 | PR NUCLEAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 79999 | PR NUCLEAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80047 | CHG BASIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80048 | BASIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80050 | CHG GENERAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80051 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80053 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80055 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80061 | CHG LIPID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80069 | CHG RENAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80074 | CHG HEPATITIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80076 | CHG HEPATIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80081 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80143 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80145 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80150 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80151 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80155 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80156 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80157 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80158 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80159 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80161 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80162 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80163 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80164 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80165 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80167 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80168 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80169 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80170 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80171 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80173 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80175 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80176 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80177 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80178 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80179 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80180 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80181 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80182 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80183 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80184 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80185 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80186 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80187 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80188 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80189 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80190 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80192 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80193 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80194 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80195 | PR ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80197 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80198 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80199 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80200 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80201 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80202 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80203 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80204 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80210 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80220 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80230 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80235 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80280 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80285 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80299 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80305 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80306 | CHG DRUG TST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80307 | CHG DRUG TST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80320 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80321 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80322 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80323 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80324 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80325 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80326 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80327 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80328 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80329 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80330 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80331 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80332 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80333 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80334 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80335 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80336 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80337 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80338 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80339 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80340 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80341 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80342 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80343 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80344 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80345 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80346 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80347 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80348 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80349 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80350 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80351 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80352 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80353 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80354 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80355 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80356 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80357 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80358 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80359 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80360 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80361 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80362 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80363 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80364 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80365 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80366 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80367 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80368 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80369 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80370 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80371 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80372 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80373 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80374 | CHG DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80375 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80376 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80377 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80400 | CHG ACTH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80402 | CHG ACTH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80406 | CHG ACTH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80408 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80410 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80412 | CHG CRH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80414 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80415 | CHG CHORNC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80416 | CHG RENIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80417 | CHG RENIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80418 | CHG PITUITARY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80420 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80422 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80424 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80426 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80428 | CHG GROWTH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80430 | CHG GROWTH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80432 | CHG INSULIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80434 | CHG INSULIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80435 | CHG INSULIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80436 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80438 | CHG TRH STIM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80439 | CHG TRH STIM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80503 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80504 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80505 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 80506 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81000 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81001 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81002 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81003 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81005 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81007 | CHG URINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81015 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81020 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81025 | CHG URINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81050 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81099 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81105 | CHG HPA-1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81106 | CHG HPA-2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81107 | CHG HPA-3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81108 | CHG HPA-4 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81109 | CHG HPA-5 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81110 | CHG HPA-6 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81111 | CHG HPA-9 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81112 | CHG HPA-15 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81120 | CHG IDH1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81121 | CHG IDH2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81161 | CHG DMD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81162 | CHG BRCA1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81163 | CHG BRCA1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81164 | CHG BRCA1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81165 | CHG BRCA1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81166 | CHG BRCA1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81167 | CHG BRCA2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81168 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81170 | CHG ABL1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81171 | PR GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81172 | PR GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81173 | CHG AR GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81174 | CHG AR GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81175 | CHG ASXL1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81176 | CHG ASXL1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81177 | CHG ATN1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81178 | CHG ATXN1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81179 | CHG ATXN2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81180 | CHG ATXN3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81181 | CHG ATXN7 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81182 | CHG ATXN8OS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81183 | CHG ATXN10 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81184 | CHG CACNA1A AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81185 | CHG CACNA1A AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81186 | CHG CACNA1A AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81187 | CHG CNBP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81188 | CHG CSTB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81189 | CHG CSTB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81190 | CHG CSTB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81191 | CHG NTRK1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81192 | CHG NTRK2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81193 | CHG NTRK3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81194 | CHG NTRK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81200 | PR ASPA GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81201 | CHG APC GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81202 | CHG APC GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81203 | CHG APC GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81204 | CHG AR GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81205 | PR BCKDHB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81206 | PR BCR/ABL1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81207 | PR BCR/ABL1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81208 | PR BCR/ABL1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81209 | PR BLM GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81210 | CHG BRAF AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81212 | CHG BRCA1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81215 | CHG BRCA1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81216 | CHG BRCA2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81217 | CHG BRCA2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81218 | CHG CEBPA AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81219 | CHG CALR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81220 | PR CFTR GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81221 | PR CFTR GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81222 | PR CFTR GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81223 | PR CFTR GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81224 | PR CFTR GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81225 | PR CYP2C19 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81226 | PR CYP2D6 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81227 | PR CYP2C9 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81228 | CHG CYTOG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81229 | CHG CYTOG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81230 | CHG CYP3A4 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81231 | CHG CYP3A5 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81232 | CHG DYPD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81233 | CHG BTK GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81234 | CHG DMPK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81235 | CHG EGFR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81236 | CHG EZH2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81237 | CHG EZH2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81238 | CHG F9 FULL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81239 | CHG DMPK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81240 | PR F2 GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81241 | PR F5 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81242 | PR FANCC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81243 | PR GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81244 | CHG FMR1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81245 | CHG FLT3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81246 | CHG FLT3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81247 | CHG G6PD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81248 | CHG G6PD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81249 | CHG G6PD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81250 | PR G6PC GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81251 | PR GBA AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81252 | CHG GJB2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81253 | CHG GJB2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81254 | CHG GJB6 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81255 | PR HEXA GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81256 | PR HFE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81257 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81258 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81259 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81260 | PR IKBKAP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81261 | PR IGH@ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81262 | PR IGH@ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81263 | PR IGH@ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81264 | PR IGK@ GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81265 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81266 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81267 | PR CHIMERISM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81268 | PR CHIMERISM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81269 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81270 | PR JAK2 GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81271 | CHG HTT GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81272 | CHG KIT GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81273 | CHG KIT GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81274 | CHG HTT GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81275 | CHG KRAS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81276 | CHG KRAS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81277 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81278 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81279 | CHG JAK2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81283 | CHG IFNL3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81284 | CHG FXN GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81285 | CHG FXN GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81286 | CHG FXN GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81287 | CHG MGMT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81288 | CHG MLH1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81289 | CHG FXN GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81290 | PR MCOLN1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81291 | PR MTHFR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81292 | PR MLH1 GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81293 | PR MLH1 GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81294 | PR MLH1 GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81295 | PR MSH2 GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81296 | PR MSH2 GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81297 | PR MSH2 GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81298 | PR MSH6 GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81299 | PR MSH6 GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81300 | PR MSH6 GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81301 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81302 | PR MECP2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81303 | PR MECP2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81304 | PR MECP2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81305 | CHG MYD88 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81306 | CHG NUDT15 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81307 | CHG PALB2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81308 | CHG PALB2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81309 | CHG PIK3CA AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81310 | PR NPM1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81311 | CHG NRAS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81312 | CHG PABPN1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81313 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81314 | CHG PDGFRA AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81315 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81316 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81317 | PR PMS2 GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81318 | PR PMS2 GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81319 | PR PMS2 GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81320 | CHG PLCG2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81321 | CHG PTEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81322 | CHG PTEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81323 | CHG PTEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81324 | CHG PMP22 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81325 | CHG PMP22 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81326 | CHG PMP22 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81327 | CHG SEPT9 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81328 | CHG SLCO1B1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81329 | CHG SMN1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81330 | PR SMPD1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81331 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81332 | PR SERPINA1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81333 | CHG TGFBI AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81334 | CHG RUNX1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81335 | CHG TPMT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81336 | CHG SMN1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81337 | CHG SMN1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81338 | CHG MPL GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81339 | CHG MPL GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81340 | PR TRB@ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81341 | PR TRB@ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81342 | PR TRG@ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81343 | CHG PPP2R2B AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81344 | CHG TBP GENE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81345 | CHG TERT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81346 | CHG TYMS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81347 | CHG SF3B1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81348 | CHG SRSF2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81349 | CHG CYTOG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81350 | CHG UGT1A1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81351 | CHG TP53 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81352 | CHG TP53 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81353 | CHG TP53 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81355 | CHG VKORC1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81357 | CHG U2AF1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81360 | CHG ZRSR2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81361 | CHG HBB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81362 | CHG HBB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81363 | CHG HBB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81364 | CHG HBB FULL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81370 | PR HLA CLASS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81371 | CHG HLA I&LI AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81372 | PR HLA CLASS I AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81373 | PR HLA CLASS I AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81374 | PR HLA I LOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81375 | PR HLA II LOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81376 | CHG HLA AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81377 | PR HLA II LOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81378 | PR HLA I&II AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81379 | PR HLA CLASS I AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81380 | PR HLA CLASS I AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81381 | PR HLA I AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81382 | CHG HLA AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81383 | PR HLA II HIGH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81400 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81401 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81402 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81403 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81404 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81405 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81406 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81407 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81408 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81410 | CHG AORTIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81411 | CHG AORTIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81412 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81413 | CARDIAC ION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81414 | GENOMIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81415 | CHG EXOME AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81416 | CHG EXOME AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81417 | CHG EXOME AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81419 | CHG EPILEPSY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81420 | CHG FETAL NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (GENETIC CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81422 | CHG FETAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81425 | CHG GENOME AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81426 | CHG GENOME AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81427 | CHG GENOME AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81430 | CHG HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81431 | CHG HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81432 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81433 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81434 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81435 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81436 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81437 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81438 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81439 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81440 | CHG NUCLEAR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81442 | CHG NOONAN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81443 | CHG GENETIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81445 | CHG GEN SEQ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81448 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81449 | PR TARGETED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81450 | CHG GEN SEQ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81451 | PR GENOMIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81455 | CHG GEN SEQ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81456 | PR TARGETED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81460 | CHG WHOLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81465 | CHG WHOLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81470 | CHG X-LINKED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81471 | CHG X-LINKED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81479 | CHG UNLISTED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81490 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81493 | CHG COR ART AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81500 | CHG ONCO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81503 | CHG ONCO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81504 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81506 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81507 | CHG FETAL NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (GENETIC CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81508 | CHG FETAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81509 | CHG FETAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81510 | CHG FETAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81511 | CHG FETAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81512 | CHG FETAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81513 | CHG NFCT DS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81514 | CHG NFCT DS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81518 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81519 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81520 | CHG ONC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81521 | CHG ONC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81522 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81523 | CHG ONC BRST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81525 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81528 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81529 | CHG ONC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81535 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81536 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81538 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81539 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81540 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81541 | CHG ONC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81542 | CHG ONC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81546 | CHG ONC THYR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81551 | CHG ONC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81552 | CHG ONC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81554 | CHG PULM DS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81560 | CHG TRNSPLJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81595 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81596 | CHG NFCT DS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 81599 | CHG UNLISTED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82009 | CHG KETONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82010 | CHG KETONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82013 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82016 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82017 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82024 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82030 | ASSAY OF ADP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82040 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82042 | CHG OTHER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82043 | CHG URINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82044 | CHG URINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82045 | PR ALBUMIN, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82075 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82077 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82085 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82088 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82103 | CHG ALPHA-1- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82104 | CHG ALPHA-1- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82105 | CHG ALPHA- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82106 | CHG ALPHA- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82107 | PR ALPHA- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82108 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82120 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82127 | CHG AMINO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82128 | CHG AMINO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82131 | CHG AMINO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82135 | CHG ASSAY, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82136 | CHG AMINO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82139 | CHG AMINO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82140 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82143 | CHG AMNIOTIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82150 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82154 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82157 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82160 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82163 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82164 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82166 | ANTI- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82172 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82175 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82180 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82190 | CHG ATOMIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82232 | CHG BETA-2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82239 | CHG BILE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82240 | CHG BILE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82247 | CHG BILIRUBIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82248 | CHG BILIRUBIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82252 | CHG FECAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82261 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82270 | BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82271 | PR BLOOD, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82272 | BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82274 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82286 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82300 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82306 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82308 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82310 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82330 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82331 | CHG CALCIUM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82340 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82355 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82360 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82365 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82370 | CHG X-RAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82373 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82374 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82375 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82376 | CHG TEST FOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82378 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82379 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82380 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82382 | ASSAY, URINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82383 | ASSAY, BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82384 | ASSAY, THREE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82387 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82390 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82397 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82415 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82435 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82436 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82438 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82441 | CHG TEST FOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82465 | ASSAY, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82480 | ASSAY, SERUM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82482 | ASSAY, RBC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82485 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82495 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82507 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82523 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82525 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82528 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82530 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82533 | CHG TOTAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82540 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82542 | CHG COL- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82550 | ASSAY OF CK NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82552 | ASSAY OF CPK NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82553 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82554 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82565 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82570 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82575 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82585 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82595 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82600 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82607 | CHG VITAMIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82608 | CHG B-12 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82610 | CHG CYSTATIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82615 | CHG TEST FOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82626 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82627 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82633 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82634 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82638 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82642 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82652 | CHG ASSAY, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82653 | CHG ELASTASE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82656 | CHG ELASTASE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82657 | CHG ENZYME NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82658 | CHG ENZYME NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82664 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82668 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82670 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82671 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82672 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82677 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82679 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82681 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82693 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82696 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82705 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82710 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82715 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82725 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82726 | CHG LONG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82728 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82731 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82735 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82746 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82747 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82757 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82759 | ASSAY OF RBC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82760 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82775 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82776 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82784 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82785 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82787 | CHG IGG1, 2, 3 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82800 | CHG BLOOD PH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82803 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82805 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82810 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82820 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82930 | CHG GASTRIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82938 | PR GASTRIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82941 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82943 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82945 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82946 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82947 | ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82948 | CHG REAGENT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82950 | CHG GLUCOSE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82951 | CHG GLUCOSE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82952 | CHG GTT- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82955 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82960 | CHG TEST FOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82963 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82965 | ASSAY OF GDH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82977 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82978 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82979 | ASSAY, RBC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 82985 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83001 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83002 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83003 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83006 | CHG GROWTH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83009 | PR H PYLORI , NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83010 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83012 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83013 | H. NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83014 | PR H PYLORI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83015 | CHG HEAVY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83018 | CHG HEAVY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83020 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83021 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83026 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83030 | CHG FETAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83033 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83036 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83037 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83045 | PR BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83050 | PR BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83051 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83060 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83065 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83068 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83069 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83070 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83080 | ASSAY OF B NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83088 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83090 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83150 | ASSAY OF FOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83491 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83497 | ASSAY OF 5- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83498 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83500 | ASSAY, FREE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83505 | ASSAY, TOTAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83516 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83518 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83519 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83520 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83521 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83525 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83527 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83528 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83529 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83540 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83550 | CHG IRON NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83570 | ASSAY OF IDH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83582 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83586 | CHG ASSAY 17- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83593 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83605 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83615 | CHG LACTATE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83625 | ASSAY OF LDH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83630 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83631 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83632 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83633 | CHG TEST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83655 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83661 | CHG ASSAY L/S NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83662 | CHG L/S RATIO, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83663 | CHG L/S RATIO, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83664 | CHG L/S RATIO, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83670 | ASSAY OF LAP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83690 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83695 | PR ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83698 | PR ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83700 | PR LIPOPRO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83701 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83704 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83718 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83719 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83721 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83722 | CHG DIR MEAS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83727 | ASSAY OF LRH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83735 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83775 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83785 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83789 | CHG MASS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83825 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83857 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83861 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83864 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83872 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83873 | CHG MYELIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83874 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83876 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83880 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83883 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83885 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83915 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83916 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83918 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83919 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83921 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83930 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83935 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83937 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83945 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83970 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83986 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83992 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 83993 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84030 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84035 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84060 | ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84066 | ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84075 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84078 | ASSAY ALKAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84080 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84081 | PHOSPHATIDYL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84085 | ASSAY OF RBC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84087 | ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84100 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84105 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84106 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84110 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84112 | CHG EVAL C/V NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84119 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84120 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84126 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84132 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84133 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84134 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84135 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84138 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84140 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84143 | ASSAY OF 17- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84144 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84145 | PROCALCITONI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84146 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84150 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84152 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84153 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84154 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84155 | PROTEIN TOT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84156 | PROTEIN TOT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84157 | PROTEIN TOT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84160 | PROTEIN TOT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84163 | PR PREG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84165 | CHG PROTEIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84166 | PR PROTEIN E- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84181 | PR PROTEIN, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84182 | PR PROTEIN, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84202 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84203 | CHG TEST RBC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84206 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84207 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84210 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84220 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84228 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84233 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84234 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84235 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84238 | ASSAY, NON- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84244 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84252 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84255 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84260 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84270 | ASSAY OF SEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84275 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84285 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84295 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84300 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84302 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84305 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84307 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84311 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84315 | CHG BODY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84375 | CHROMATOGR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84376 | SUGARS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84377 | SUGARS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84378 | SUGARS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84379 | SUGARS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84392 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84402 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84403 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84425 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84430 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84431 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84432 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84433 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84436 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84437 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84439 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84442 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84443 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84445 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84446 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84449 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84450 | TRANSFERASE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84460 | TRANSFERASE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84466 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84478 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84479 | THYROID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84480 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84481 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84482 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84484 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84485 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84488 | TRYPSIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84490 | TRYPSIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84510 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84512 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84520 | ASSAY UREA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84525 | CHG UREA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84540 | CHG ASSAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84545 | CHG UREA-N NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84550 | ASSAY OF URIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84560 | ASSAY OF URIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84577 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84578 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84580 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84583 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84585 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84586 | ASSAY OF VIP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84588 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84590 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84591 | ASSAY OF NOS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84597 | ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84600 | CHG ASSAY OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84620 | CHG XYLOSE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84630 | ASSAY OF ZINC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84681 | ASSAY OF C- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84702 | CHORIONIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84703 | CHORIONIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 84704 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85002 | CHG BLEEDING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85004 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85007 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85008 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85009 | CHG MANUAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85013 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85014 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85018 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85025 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85027 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85032 | CHG MANUAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85041 | CHG RED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85044 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85045 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85046 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85048 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85049 | CHG PLATELET NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85055 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85060 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85097 | CHG BONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85130 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85170 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85175 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85210 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85220 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85230 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85240 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85244 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85245 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85246 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85247 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85260 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85270 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85280 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85290 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85291 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85292 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85293 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85300 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85301 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85302 | CHG CLOT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85303 | CHG CLOT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85305 | CHG CLOT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85306 | CHG CLOT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85307 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85335 | CHG FACTOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85337 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85345 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85347 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85348 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85360 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85362 | FIBRIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85366 | FIBRIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85370 | FIBRIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85378 | FIBRIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85379 | FIBRIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85380 | FIBRIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85384 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85385 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85390 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85396 | CHG CLOTTING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85397 | CHG CLOTTING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85400 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85410 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85415 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85420 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85421 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85441 | CHG HEINZ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85445 | CHG HEINZ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85460 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85461 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85475 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85520 | CHG HEPARIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85525 | CHG HEPARIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85530 | CHG HEPARIN- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85536 | CHG IRON NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85540 | CHG WBC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85547 | CHG RBC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85549 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85555 | CHG RBC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85557 | CHG RBC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85576 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85597 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85598 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85610 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85611 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85612 | CHG VIPER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85613 | CHG RUSSELL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85635 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85651 | CHG RBC SED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85652 | CHG RBC SED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85660 | CHG RBC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85670 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85675 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85705 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85730 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85732 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85810 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 85999 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86000 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86001 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86003 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86005 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86008 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86015 | CHG ACTIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86021 | CHG WBC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86022 | CHG PLATELET NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86023 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86036 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86037 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86038 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86039 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86051 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86052 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86053 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86060 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86063 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86077 | CHG PHYS BLD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86078 | CHG PHYS BLD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86079 | CHG PHYS BLD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86140 | CHG C- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86141 | CHG C- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86146 | CHG BETA 2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86147 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86148 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86152 | CHG CELL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86153 | CHG CELL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86160 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86161 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86162 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86171 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86200 | PR CYCLIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86215 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86225 | CHG DNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86226 | CHG DNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86231 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86235 | CHG NUCLEAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86255 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86256 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86258 | CHG GLIADIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86277 | CHG GROWTH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86280 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86294 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86300 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86301 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86304 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86305 | CHG HUMAN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86308 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86309 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86310 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86316 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86317 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86318 | CHG IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86320 | CHG SERUM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86325 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86327 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86328 | CHG IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 5/12/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86329 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86331 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86332 | CHG IMMUNE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86334 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86335 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86336 | CHG INHIBIN A NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86337 | CHG INSULIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86340 | CHG INTRINSIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86341 | CHG ISLET NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86343 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86344 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86352 | CHG CELLULAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86353 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86355 | PR B CELLS, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86356 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86357 | PR NK CELLS, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86359 | CHG T CELLS, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86360 | CHG T CELL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86361 | CHG T CELL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86362 | CHG MOG-IGG1 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86363 | CHG MOG-IGG1 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86364 | CHG TISSUE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86367 | PR STEM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86376 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86381 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86382 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86384 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86386 | PR NUCLEAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86403 | CHG PARTICLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86406 | CHG PARTICLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86408 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86409 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 5/12/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86413 | CHG SEV AQT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86430 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86431 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86480 | CHG TB TEST, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86481 | CHG TB TEST, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86485 | CHG SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86486 | CHG SKIN TEST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86490 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86510 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86580 | CHG TB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86590 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86592 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86593 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86596 | CHG VOLTAGE- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86602 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86603 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86606 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86609 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86611 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86612 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86615 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86617 | CHG LYME NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86618 | CHG LYME NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86619 | CHG BORRELIA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86622 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86625 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86628 | CHG CANDIDA, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86631 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86632 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86635 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86638 | CHG Q FEVER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86641 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86644 | CHG CMV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86645 | CHG CMV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86648 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86651 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86652 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86653 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86654 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86658 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86663 | CHG EPSTEIN- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86664 | CHG EPSTEIN- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86665 | CHG EPSTEIN- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86666 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86668 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86671 | CHG FUNGUS, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86674 | CHG GIARDIA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86677 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86682 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86684 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86687 | CHG HTLV I NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86688 | CHG HTLV-II NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86689 | CHG HTLV/HIV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86692 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86694 | CHG HERPES NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86695 | CHG HERPES NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86696 | CHG HERPES NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86698 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86701 | CHG HIV-1 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86702 | CHG HIV-2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86703 | PR ANTIBODY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86704 | CHG HEP B NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86705 | CHG HEP B NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86706 | CHG HEPATITIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86707 | CHG HEPATITIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86708 | CHG HEPATITIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86709 | CHG HEPATITIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86710 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86711 | CHG ANTIBODY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86713 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86717 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86720 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86723 | CHG LISTERIA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86727 | CHG LYMPH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86732 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86735 | CHG MUMPS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86738 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86741 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86744 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86747 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86750 | CHG MALARIA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86753 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86756 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86757 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86759 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86762 | CHG RUBELLA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86765 | CHG RUBEOLA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86768 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86769 | CHG ANTB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86771 | CHG SHIGELLA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86774 | CHG TETANUS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86777 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86778 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86780 | CHG ANTIBODY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86784 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86787 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86788 | PR WEST NILE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86789 | PR WEST NILE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86790 | CHG VIRUS, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86793 | CHG YERSINIA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86794 | CHG ZIKA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86800 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86803 | CHG HEPATITIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86804 | CHG HEP C AB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86805 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86806 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86807 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86808 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86812 | CHG HLA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86813 | CHG HLA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86816 | CHG HLA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86817 | CHG HLA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86821 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86825 | CHG HLA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86826 | CHG HLA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86828 | CHG ANTIBODY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86829 | CHG ANTIBODY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86830 | CHG ANTIBODY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86831 | CHG ANTIBODY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86832 | CHG ANTIBODY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86833 | CHG ANTIBODY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86834 | CHG ANTIBODY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86835 | CHG ANTIBODY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86849 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86850 | CHG RBC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86860 | CHG RBC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86870 | CHG RBC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86880 | ANTIHUMAN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86885 | ANTIHUMAN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86886 | ANTIHUMAN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86890 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86891 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86900 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86901 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86902 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86904 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86905 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86906 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86910 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86911 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86920 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86921 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86922 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86923 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86927 | CHG PLASMA, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86930 | CHG FROZEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86931 | CHG FROZEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86932 | CHG FROZEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86940 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86941 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86945 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86950 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86960 | PR VOL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86965 | CHG POOLING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86970 | CHG RBC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86971 | CHG RBC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86972 | CHG RBC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86975 | CHG RBC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86976 | CHG RBC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86977 | CHG RBC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86978 | CHG RBC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86985 | CHG SPLIT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 86999 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87003 | CHG SMALL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87015 | CHG SPECIMEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87040 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87045 | CHG STOOL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87046 | CHG STOOL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87070 | CHG CULTURE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87071 | CHG CULTURE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87073 | CHG CULTURE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87075 | CHG CULTURE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87076 | CHG CULT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87077 | CHG BACTERIA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87081 | CHG BACTERIA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87084 | CHG CULTURE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87086 | CHG URINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87088 | PR URINE BACT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87101 | CHG CULTURE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87102 | CHG FUNGUS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87103 | CHG BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87106 | CHG CULTURE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87107 | CHG FUNGUS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87109 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87110 | CHG CULTURE, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87116 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87118 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87140 | CHG CULTURE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87143 | CHG CULTURE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87147 | CHG CULTURE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87149 | CHG CULTURE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87150 | CHG CULTYP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87152 | CHG CULTURE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87153 | CHG CULTYP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87154 | CHG CULTURE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87158 | CHG CULTURE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87164 | CHG DARK NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87166 | CHG DARK NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87168 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87169 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87172 | CHG PINWORM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87176 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87177 | CHG OVA AND NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87181 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87184 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87185 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87186 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87187 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87188 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87190 | CHG TB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87197 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87205 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87206 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87207 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87209 | PR SMEAR, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87210 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87220 | CHG TISSUE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87230 | CHG ASSAY, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87250 | CHG VIRUS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87252 | CHG VIRUS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87253 | CHG VIRUS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87254 | CHG VIRUS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87255 | CHG VIRUS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87260 | CHG INF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87265 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87267 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87269 | CHG GIARDIA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87270 | CHG CHYLMD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87271 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87272 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87273 | CHG HERPES NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87274 | CHG HERPES NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87275 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87276 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87278 | CHG LEGION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87279 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87280 | CHG RESP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87281 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87283 | CHG RUBEOLA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87285 | CHG TREPON NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87290 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87299 | CHG AG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87300 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87301 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87305 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87320 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87324 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87327 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87328 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87329 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87332 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87335 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87336 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87337 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87338 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87339 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87340 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87341 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87350 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87380 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87385 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87389 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87390 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87391 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87400 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87420 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87425 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87426 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87427 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87428 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87430 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87449 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87451 | CHG IAAD IA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87467 | PR HEPATITIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87468 | PR INFECTIOUS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87469 | PR BABESIA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87478 | PR BORRELIA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87480 | CHG CANDIDA, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87481 | CHG CANDIDA, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87482 | CHG CANDIDA, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87483 | INFECTIOUS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87484 | PR EHRLICHIA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87485 | CHG CHYLMD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87486 | CHG CHYLMD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87487 | CHG CHYLMD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87490 | CHG CHYLMD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87491 | CHG CHYLMD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87492 | CHG CHYLMD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87493 | CLOSTRIDIUM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87495 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87496 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87497 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87498 | CHG IADNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87500 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87501 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87502 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87503 | CHG NFCT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87505 | CHG NFCT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87506 | CHG IADNA- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87507 | CHG IADNA- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87510 | CHG GARDNER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87511 | CHG GARDNER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87512 | CHG GARDNER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87520 | CHG HEPATITIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87521 | CHG IADNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87522 | CHG IADNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87523 | DETECTION OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87525 | CHG HEPATITIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87526 | CHG HEPATITIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87527 | CHG HEPATITIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87528 | CHG HSV, DNA, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87529 | CHG HSV, DNA, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87530 | CHG HSV, DNA, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87531 | CHG HHV-6, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87532 | CHG HHV-6, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87533 | CHG HHV-6, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87534 | CHG HIV-1, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87535 | CHG IADNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87536 | CHG IADNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87537 | CHG HIV-2, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87538 | CHG IADNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87539 | CHG IADNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87540 | CHG LEGION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87541 | CHG LEGION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87542 | CHG LEGION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87550 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87551 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87552 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87555 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87556 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87557 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87560 | CHG M.AVIUM- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87561 | CHG M.AVIUM- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87562 | CHG M.AVIUM- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87563 | CHG IADNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87580 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87581 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87582 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87590 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87591 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87592 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87593 | IADNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87623 | CHG IADNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87624 | CHG IADNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87625 | CHG IADNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87631 | CHG IADNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87632 | CHG IADNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87633 | CHG IADNA AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87634 | CHG IADNA NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87635 | CHG IADNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 5/12/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87636 | CHG IADNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87637 | CHG IADNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 5/12/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87640 | PR STAPH A, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87641 | PR MRSA, DNA, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87650 | CHG STREP A, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87651 | CHG STREP A, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87652 | CHG STREP A, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87653 | PR STREP B, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87660 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87661 | CHG IADNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87662 | CHG IADNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87797 | CHG DETECT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87798 | CHG DETECT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87799 | CHG DETECT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87800 | CHG DETECT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87801 | CHG DETECT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87802 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87803 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87804 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87806 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87807 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87808 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87809 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87810 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87811 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87850 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87880 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87899 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87900 | PR INFECT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87901 | CHG HIV 1 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87902 | CHG HEPATITIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87903 | CHG HIV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87904 | PR HIV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87905 | CHG INFECT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87906 | CHG HIV 1 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87910 | CHG NFCT AGT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87912 | CHG NFCT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87913 | INFECTIOUS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 87999 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88000 | CHG AUTOPSY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88005 | CHG AUTOPSY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88007 | CHG AUTOPSY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88012 | CHG AUTOPSY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88014 | CHG AUTOPSY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88016 | CHG AUTOPSY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88020 | CHG AUTOPSY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88025 | CHG AUTOPSY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88027 | CHG AUTOPSY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88028 | CHG AUTOPSY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88029 | CHG AUTOPSY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88036 | CHG LTD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88037 | CHG LTD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88040 | CHG FORENSIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88045 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88099 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88104 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88106 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88108 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88112 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88120 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88121 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88125 | CHG FORENSIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88130 | CHG SEX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88140 | CHG SEX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88141 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88142 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88143 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88147 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88148 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88150 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88152 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88153 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88155 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88160 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88161 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88162 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88164 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88165 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88166 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88167 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88172 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88173 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88174 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88175 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88177 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88182 | CHG CELL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88184 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88185 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88187 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88188 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88189 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88199 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88230 | CHG TISSUE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88233 | CHG TISSUE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88235 | CHG TISSUE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88237 | CHG TISSUE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88239 | CHG TISSUE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88240 | CHG CELL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88241 | CHG FROZEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88245 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88248 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88249 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88261 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88262 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88263 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88264 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88267 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88269 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88271 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88272 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88273 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88274 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88275 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88280 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88283 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88285 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88289 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88291 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88299 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88300 | CHG SURG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88302 | CHG SURG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88304 | CHG SURG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88305 | CHG SURG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88307 | CHG SURG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88309 | CHG SURG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88311 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88312 | PR SPECIAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88313 | PR SPCL STN 2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88314 | PR SPECIAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88319 | PR SPECIAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88321 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88323 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88325 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88329 | CHG PATH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88331 | CHG PATH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88332 | CHG PATH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88333 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88334 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88341 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88342 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88344 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88346 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88348 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88350 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88355 | CHG ANALYSIS, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88356 | CHG ANALYSIS, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88358 | CHG ANALYSIS, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88360 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88361 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88362 | CHG NERVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88363 | CHG EXAM & AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88364 | CHG IN SITU NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88365 | CHG IN SITU NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88366 | CHG IN SITU NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88367 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88368 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88369 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88371 | CHG PROTEIN, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88372 | CHG PROTEIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88373 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88374 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88375 | CHG OPTICAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88377 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88380 | MICRODISSECT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88381 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88387 | CHG MACRO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88388 | CHG MACR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88399 | CHG SURGICAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88720 | CHG BILIRUBIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88738 | CHG HGB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88740 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88741 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 88749 | CHG UNLISTED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89049 | PR CAFFEINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89050 | CHG CELL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89051 | CHG BODY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89055 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89060 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89125 | CHG SPECIMEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89160 | CHG EXAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89190 | CHG NASAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89220 | CHG SPUTUM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89230 | CHG SWEAT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89240 | CHG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89250 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89251 | CHG CULTURE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89253 | CHG EMBRYO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89254 | CHG OOCYTE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89255 | CHG PREPARE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89257 | CHG SPERM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89258 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89259 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89260 | CHG SPERM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89261 | CHG SPERM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89264 | CHG SPERM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89268 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89272 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89280 | CHG ASSIST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89281 | CHG ASSIST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89290 | CHG BIOPSY, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89291 | CHG BIOPSY, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89300 | CHG SEMEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89310 | CHG SEMEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89320 | SEMEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89321 | SEMEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89322 | CHG SEMEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89325 | CHG SPERM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89329 | CHG SPERM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89330 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89331 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89335 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89337 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89342 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89343 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89344 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89346 | CHG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89352 | CHG THAWING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89353 | CHG THAWING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89354 | CHG THAW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89356 | CHG THAWING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 89398 | CHG UNLISTED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90371 | PR HEPB IG, IM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90375 | PR RABIES IG, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90376 | PR RABIES IG, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90377 | PR RABIES IG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90384 | PR RH IG, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90385 | PR RH IG, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90460 | PR IM ADM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90461 | PR IM ADM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90471 | PR IMMUNIZ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90472 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90473 | PR IMMUNIZ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90474 | PR IMMUNIZ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90476 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90477 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90480 | IMMUNIZATION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90581 | PR ANTHRAX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90585 | PR BCG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90611 | SMALLPOX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90619 | PR MENACWY- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90620 | PR MENB-4C NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90621 | PR MENB-FHBP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90622 | VACCINIA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90623 | CHIKUNGUNYA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90625 | PR CHOLERA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90626 | PR TICK- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90627 | PR TICK- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90630 | PR INFLUENZA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90632 | PR HEPA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90633 | PR HEPA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90636 | PR HEPA/HEPB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90647 | PR HIB PRP- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90648 | PR HIB PRP-T NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90651 | PR 9VHPV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90654 | PR INFLUENZA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90655 | PR IIV3 VACC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90656 | PR IIV3 VACC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90657 | PR IIV3 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90658 | PR IIV3 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90660 | PR LAIV3 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90661 | PR CCIIV3 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90662 | PR IIV VACCINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90670 | PR PCV13 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90671 | PR PCV15 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90672 | PR LAIV4 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90673 | PR RIV3 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90674 | PR CCIIV4 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90675 | PR RABIES NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90677 | PR PCV20 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90678 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90679 | RESPIRATORY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90680 | PR RV5 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90681 | PR RV1 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90682 | PR RIV4 VACC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90685 | PR IIV4 VACC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90686 | PR IIV4 VACC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90687 | PR IIV4 VACC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90688 | PR IIV4 VACC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90690 | PR TYPHOID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90691 | PR TYPHOID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90694 | PR AIIV4 VACC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90696 | PR DTAP-IPV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90697 | PR DTAP-IPV- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90698 | PR DTAP- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90700 | DTAP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90702 | PR DT VACCINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90707 | PR MMR VIRUS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90710 | PR COMBINED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90713 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90714 | PR TD VACCINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90715 | PR TDAP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90716 | PR VAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90717 | PR YELLOW NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90723 | PR DTAP-HEPB- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90732 | PR PPSV23 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90734 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90738 | PR JAPANESE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90739 | HEPATITIS NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, 9/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90740 | PR HEPB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90743 | PR HEPB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90744 | PR HEPB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90746 | PR HEPB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90747 | PR HEPB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90756 | PR CCIIV4 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90758 | PR ZAIRE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90759 | PR HEP B VACC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90791 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90792 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90832 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90833 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90834 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90836 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90837 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90838 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90846 | PR FAMILY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90847 | PR FAMILY NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90853 | PR GROUP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90870 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90875 | PR INDIV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90876 | PR INDIV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90899 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90901 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90911 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90912 | PR BFB TRAING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90913 | PR BFB TRAING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90935 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90937 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90940 | PR HEMODIA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90945 | PR DIALYSIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90947 | PR DIALYSIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90951 | PR ESRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90952 | PR ESRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90953 | PR ESRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90954 | PR ESRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90955 | PR ESRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90956 | PR ESRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90957 | PR ESRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90958 | PR ESRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90959 | PR ESRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90960 | PR ESRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90961 | PR ESRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90962 | PR ESRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90963 | PR ESRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90964 | PR ESRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90965 | PR ESRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90966 | PR ESRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90967 | PR ESRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90968 | PR ESRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90969 | PR ESRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90970 | PR ESRD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90989 | PR DIALYSIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90993 | PR DIALYSIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90997 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 90999 | PR DIALYSIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91010 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91035 | PR GERD TST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91065 | PR BREATH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91113 | PR GI TRACT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91200 | PR LIVER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91300 | PR SARSCOV2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91301 | PR SARSCOV2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 8/12/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91303 | PR SARSCOV2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 8/12/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91304 | PR SARSCOV2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91306 | SEVERE ACUTE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91307 | PR COVID 5-11 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91308 | PR PFIZER 2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91309 | SARSCOV2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91311 | SEVERE ACUTE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 3/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91312 | SARSCOV2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91313 | SARSCOV2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91314 | SARSCOV2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91315 | SARSCOV2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91316 | MODERNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 3/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91317 | PFIZER- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91318 | SEVERE ACUTE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91319 | SEVERE ACUTE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91320 | SEVERE ACUTE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91321 | SEVERE ACUTE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 91322 | SEVERE ACUTE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92002 | PR EYE EXAM, AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92004 | PR EYE EXAM, AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92012 | PR EYE EXAM AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92014 | PR EYE EXAM & AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92015 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92018 | PR NEW EYE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92020 | PR SPECIAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92025 | PR CORNEAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92060 | PR SPECIAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92065 | PR ORTHOPTIC AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92071 | PR FIT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92072 | PR FITTING AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92081 | PR VISUAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92082 | PR VISUAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92083 | PR VISUAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92100 | PR SERIAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92133 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92134 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92135 | OPTHALMIC AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92136 | PR OPHTHAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92201 | PR OPSCPY AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92202 | PR OPSCPY AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92225 | PR SPECIAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92226 | PR SPECIAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92227 | PR IMG RETINA AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92228 | PR IMG RETINA AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92229 | PR ORTHOPTIC AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92230 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92235 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92240 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92242 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92250 | PR FUNDAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92260 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92274 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92313 | PR CONTACT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92502 | PR EAR AND NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92504 | PR EAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92507 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92508 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92517 | PR CERVICAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92518 | PR OCULAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92519 | PR CERVICAL & NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92521 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92522 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92523 | PR EVAL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92524 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92526 | PR ORAL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92531 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92532 | PR POSITIONAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92533 | PR CALORIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92534 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92540 | PR VSTBLR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92541 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92542 | PR POSITIONAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92543 | PR CALORIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92544 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92545 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92546 | PR SINUSOIDAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92550 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92551 | PR PURE TONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92552 | PR PURE TONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92553 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92555 | PR SPEECH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92556 | PR SPEECH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92557 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92558 | PR EVOKED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92562 | PR LOUDNESS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92563 | PR TONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92565 | PR STENGER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92567 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92568 | PR ACOUSTIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92569 | PR ACOUSTIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92570 | PR ACOUSTIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92571 | PR FILTERED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92572 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92573 | PR LOMBARD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92575 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92576 | PR SYNTHETIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92577 | PR STENGER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92579 | PR VISUAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92582 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92583 | PR SELECT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92584 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92587 | PR DISTORT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92588 | PR DISTRT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92590 | PR HEARING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92591 | PR HEARING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92592 | PR HEARING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92593 | PR HEARING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92601 | DX ANAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92602 | DX ANAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92603 | PR DX ANAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92604 | PR DX ANAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92610 | PR EVAL,ORAL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92611 | SWALLOW STUDIES ( | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92612 | PR FLEXIBLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92614 | PR FLEXIBLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92616 | PR FLEXIBLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92617 | ), SPEECH | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92622 | ANALYSIS, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92623 | ANALYSIS, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92650 | PR AEP SCR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92651 | PR AEP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92652 | PR AEP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 92653 | PR AEP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93000 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93005 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93010 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93012 | PR TELEPH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93014 | PR REPORT ON NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93015 | PR CV STRS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93016 | PR CV STRS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93017 | PR CARDIAC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93018 | PR CARDIAC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93024 | PR CARDIAC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93025 | PR MICROVOLT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93040 | PR RHYTHM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93041 | PR RHYTHM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93042 | PR RHYTHM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93050 | PR ART PRESS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93224 | PR XTRNL ECG NO AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 5/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93225 | PR EXT ECG NO AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 5/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93226 | PR EXT ECG NO AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 5/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93227 | PR XTRNL ECG NO AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 5/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93241 | PR EXTERNAL NO AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 5/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93242 | PR EXTERNAL NO AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 5/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93243 | PR EXTERNAL NO AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 5/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93244 | PR EXTERNAL NO AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 5/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93245 | PR EXTERNAL NO AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 5/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93246 | PR EXTERNAL NO AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 5/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93247 | PR EXTERNAL NO AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 5/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93248 | PR EXTERNAL NO AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 5/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93287 | PR PERI-PX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93290 | PR INTERROG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93303 | PR ECHO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93304 | PR ECHO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93306 | PR ECHO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93307 | PR ECHO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93308 | PR ECHO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93312 | PR ECHO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93313 | PR ECHO R-T NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93314 | PR ECHO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93315 | PR ECHO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93316 | PR ECHO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93317 | PR ECHO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93318 | PR ECHO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93319 | PR 3D ECHO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93320 | PR DOPPLER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93321 | PR DOPPLER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93325 | PR DOPPLER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93350 | PR ECHO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93351 | PR ECHO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93352 | PR ECHO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93355 | PR ECHO TEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93593 | PR R HRT CATH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93594 | PR R HRT CATH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93595 | PR L HRT CATH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93596 | PR R&L HRT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93597 | PR R&L HRT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93598 | PR CAR OUTP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93880 | PR DUPLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93882 | PR DUPLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93886 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93888 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93890 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93892 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93893 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93895 | PR CAROTID AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93922 | PR NON-INVAS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93923 | PR NON- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93924 | PR NON- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93925 | PR DUPLEX LO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93926 | PR DUPLEX LO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93930 | PR DUPLEX UP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93931 | PR DUPLEX UP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93970 | PR DUPLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93971 | PR DUPLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93975 | PR DUPLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93976 | PR DUPLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93978 | PR DUPLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93979 | PR DUPLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93980 | PR PENILE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93981 | PR PENILE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93985 | PR DUPLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93986 | PR DUPLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93990 | PR DUPLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 93998 | PR UNLISTED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94010 | PR BREATHING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94011 | PR MEAS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94012 | PR MEAS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94013 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94014 | PR PT-INITIATE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94015 | PR PT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94016 | PR PATIENT- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94060 | PR EVAL OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94070 | PR EVAL OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94150 | PR VITAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94200 | PR LUNG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94375 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94450 | PR HYPOXIA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94452 | PR HIGH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94453 | PR HIGH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94610 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94617 | PR XERS TST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94618 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94619 | PR XERS TST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94620 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94621 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94625 | PR PHYS/QHP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94626 | PR PHYS/QHP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94640 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94642 | PR AEROSOL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94644 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94645 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94656 | PR INITIAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94657 | PR CONT. NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94660 | PR POS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94662 | PR NEG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94664 | PR DEMO &/OR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94667 | PR CHEST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94668 | PR CHEST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94669 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94680 | PR EXHALED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94681 | PR EXHALED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94690 | PR EXHALED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94720 | PR CARBON NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94725 | PR MEMBRANE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94726 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94727 | PR GAS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94728 | PR AIRWAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94729 | PR DIFFUSING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94760 | PR NONINVASV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94761 | PR NONINVASV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94762 | PR NONINVASV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94772 | BREATH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 94774 | PR PEDIATRIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95004 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95010 | PR PERCUT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95012 | PR NITRIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95015 | PR INTRACUT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95017 | PR ALLG TSTG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95018 | PR ALLG TEST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95024 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95027 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95028 | PR ALLERGY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95044 | PR ALLERGY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95052 | PR PHOTO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95056 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95060 | PR EYE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95065 | PR NOSE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95070 | PR INHLJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95076 | PR INGESTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95079 | PR INGESTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95115 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95117 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95120 | PR PROF SVCS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95125 | PR PROF SVCS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95130 | PR PROF SVCS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95131 | PR PROF SVCS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95132 | PR PROF SVCS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95133 | PR PROF SVCS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95134 | PR PROF SVCS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95144 | PR PROFES NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95145 | PR PROFES NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95146 | PR ANTIGEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95147 | PR ANTIGEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95148 | PR ANTIGEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95149 | PR ANTIGEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95165 | PR PROFES NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95170 | PR ANTIGEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95180 | PR RAPID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95199 | PR ALLERGY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95250 | PR CONT GLUC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95251 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95700 | PR EEG CONT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95705 | PR EEG W/O AUTHORIZATION REQUIRED TMPPM, INTERQUAL CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95706 | PR EEG W/O NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95707 | PR EEG W/O AUTHORIZATION REQUIRED TMPPM, INTERQUAL CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95708 | PR EEG W/O NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95709 | PR EEG W/O AUTHORIZATION REQUIRED TMPPM, INTERQUAL CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95710 | PR EEG W/O NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95711 | PR VEEG BY AUTHORIZATION REQUIRED TMPPM, INTERQUAL CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95712 | PR VEEG BY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95713 | PR VEEG BY AUTHORIZATION REQUIRED TMPPM, INTERQUAL CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95714 | PR VEEG BY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95715 | PR VEEG BY AUTHORIZATION REQUIRED TMPPM, INTERQUAL CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95716 | PR VEEG BY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95717 | PR EEG AUTHORIZATION REQUIRED TMPPM, INTERQUAL CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95718 | PR EEG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95719 | PR EEG AUTHORIZATION REQUIRED TMPPM, INTERQUAL CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95720 | PR EEG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95721 | PR EEG AUTHORIZATION REQUIRED TMPPM, INTERQUAL CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95722 | PR EEG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95723 | PR EEG AUTHORIZATION REQUIRED TMPPM, INTERQUAL CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95724 | PR EEG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95725 | PR EEG AUTHORIZATION REQUIRED TMPPM, INTERQUAL CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95726 | PR EEG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95782 | PR POLYSOM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95783 | PR POLYSOM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95800 | PR SLEEP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95801 | PR SLEEP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95803 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95805 | PR MULTIPLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95806 | PR SLEEP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/6/2016 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95807 | PR SLEEP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95808 | PR POLYSOM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95810 | PR POLYSOM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95811 | PR POLYSOM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95812 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95813 | PR EEG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95816 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95819 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95822 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95824 | PR EEG EVAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95827 | PR EEG,ALL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95829 | PR SURGERY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95830 | PR INSERTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95860 | PR EMG, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95861 | PR EMG, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95863 | PR EMG, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95864 | PR EMG, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95865 | PR EMG, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95866 | PR EMG, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95867 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95868 | PR EMG, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95869 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95870 | PR EMG,1 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95872 | PR EMG, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95873 | PR ELECTRIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95874 | PR NEEDLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95875 | PR ISCHEM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95885 | PR NEEDLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95886 | PR NEEDLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95887 | PR NEEDLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95900 | PR NERVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95903 | PR MOTOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95904 | PR NERVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95905 | PR MOTOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95907 | PR MOTOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95908 | PR MOTOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95909 | PR MOTOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95910 | PR MOTOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95911 | PR MOTOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95912 | PR MOTOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95913 | PR MOTOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95919 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95920 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95928 | PR C MOTOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95929 | PR C MOTOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95930 | PR VISUAL EP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95933 | PR BLINK NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95934 | PR H REFLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95936 | PR H REFLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95937 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95938 | PR SHORT- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95939 | PR CTR MOTR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95940 | PR IONM 1 ON 1 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95941 | PR IONM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95954 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95955 | PR EEG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95956 | PR EEG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95957 | PR EEG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95958 | PR EEG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95961 | PR FUNCJAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95962 | PR FUNCJAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95965 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95966 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 95967 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96040 | PR GENETIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96105 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96110 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96112 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96113 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96116 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96121 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96127 | PR BEHAV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96130 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96131 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96132 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96133 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96136 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96137 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96156 | PR HEALTH NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96158 | PR HEALTH NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96159 | PR HEALTH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96164 | PR HEALTH NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96165 | PR HEALTH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96167 | PR HEALTH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96168 | PR HEALTH NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96170 | PR HEALTH NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96171 | PR HEALTH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96360 | PR IV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96361 | PR IV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96365 | PR IV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96366 | PR IV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96367 | PR IV INFUSION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96368 | PR IV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96369 | PR SUBCUT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96370 | PR SUBCUT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96371 | PR SUBCUT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96372 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96373 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96374 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96375 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96376 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96377 | PR APPL ON- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96379 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96401 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96402 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96405 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96406 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96408 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96409 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96410 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96411 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96412 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96413 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96414 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96415 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96416 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96417 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96420 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96422 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96423 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96425 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96440 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96445 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96446 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96450 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96520 | PR PUMP PORT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96521 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96522 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96523 | PR IRRIG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96530 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96542 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96545 | PR PROVIDE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96547 | INTRAOPERATI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96548 | INTRAOPERATI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96549 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 96999 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97010 | PR HOT OR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97012 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97014 | PR ELECTRIC NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97016 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97018 | PR PARAFFIN NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97020 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97022 | PR WHIRLPOOL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97024 | PR DIATHERMY NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97026 | PR INFRARED NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97028 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97032 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97033 | PR ELECTRIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97034 | PR CONTRAST NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97035 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97036 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97037 | LOW-LEVEL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97039 | PR PHYSICAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97110 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97112 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97113 | PR AQUATIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97116 | PR GAIT NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97124 | PR MASSAGE NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97127 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97129 | PR THER IVNTJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97130 | PR THER IVNTJ NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97139 | PR PHYSICAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97140 | PR MANUAL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97150 | PR GROUP NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97151 | PR BEHAVIOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97152 | PR BEHAVIOR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97153 | PR ADAPTIVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97154 | PR GROUP NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97155 | PR ADAPT BHV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97156 | PR FAMILY NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97157 | PR MULTIPLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97158 | PR GRP ADAPT NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97161 | PR PHYSICAL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97162 | PR PHYSICAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97163 | PR PHYSICAL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97164 | PR PHYSICAL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97165 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97166 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97167 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97168 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97530 | PR THERAPEUT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97532 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97533 | PR SENSORY NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97535 | PR SELF- NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97537 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97542 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97545 | PR WORK NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97546 | PR WORK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97597 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97598 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97602 | PR RMVL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97605 | PR NEGATIVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97606 | PR NEGATIVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97607 | PR NEG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97608 | PR NEG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97610 | PR LOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97802 | PR MED NUTR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97803 | PR MED NUTR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97804 | PR MED NUTR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97810 | PR ACUPUNCT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 97811 | PR ACUPUNCT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 98925 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 98926 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 98927 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 98928 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 98929 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 98940 | PR CHIROPRAC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 98941 | PR CHIROPRAC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 98942 | PR CHIROPRAC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 98943 | PR CHIROPRAC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99000 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99001 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 5/12/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99050 | PR MEDICAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99072 | PR ADDL SUPL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99080 | PR SPECIAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99091 | PR COLLJ & AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 3/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99151 | PR MOD SED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99152 | PR MOD SED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99153 | PR MOD SED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99170 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99202 | PR NEW AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99203 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99204 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99205 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99211 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99212 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99213 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99214 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99215 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99217 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99221 | PR INITIAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99222 | PR INITIAL AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99223 | PR INITIAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99231 | PR SBSQ AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99232 | PR SBSQ AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99233 | PR SBSQ AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99242 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99243 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99244 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99245 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99252 | PR INITL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99253 | PR INITL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99254 | PR INITL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99255 | PR INITIAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99282 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99283 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99284 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99285 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99366 | PR TEAM AUTHORIZATION REQUIRED TMHP TMPPM CHILDREN CLINICAL INFORMATION S, SK C, CP 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99377 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99378 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99381 | PREVENTIVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 4/28/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99382 | PREVENTIVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 4/28/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99383 | PREVENTIVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 4/28/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99384 | PREVENTIVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 4/28/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99385 | PREVENTIVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 4/28/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99391 | PREVENTIVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 4/28/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99392 | PREVENTIVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 4/28/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99393 | PREVENTIVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 4/28/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99394 | PREVENTIVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 4/28/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99395 | PREVENTIVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 4/28/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99406 | PR TOBACCO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK C, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99407 | PR TOBACCO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK C, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99408 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99417 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99418 | PR AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99421 | PR ONLINE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99422 | PR ONLINE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99441 | PR PHYS/QHP AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99442 | PR PHYS/QHP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99443 | PR PHYS/QHP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99468 | PR INITIAL AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99469 | PR AUTHORIZATION REQUIRED INTERQUAL CLINICAL INFORMATION C, S, SK CP 1/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99473 | PR SELF-MEAS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99474 | PR SELF-MEAS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99492 | PR 1ST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99493 | PR SBSQ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99494 | PR 1ST/SBSQ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| 99499 | PR UNLISTED NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0021 | PR OUTSIDE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0080 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0090 | PR INTEREST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0100 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0110 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0120 | PR NONER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0130 | PR NONER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0140 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0160 | PR NONER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0170 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0180 | PR NONER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0190 | PR NONER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0200 | PR NONER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0210 | PR NONER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0225 | PR NEONATAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0380 | PR BASIC LIFE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0382 | PR BASIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0384 | PR BLS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0390 | PR ADVANCED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0392 | PR ALS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0394 | PR ALS IV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0396 | PR ALS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0398 | PR ALS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0420 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0422 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0424 | PR EXTRA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0425 | PR GROUND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0426 | PR ALS 1 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0427 | PR ALS1- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0428 | PR BLS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0429 | PR BLS- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0430 | PR FIXED WING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0431 | PR ROTARY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0432 | PR PI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0433 | PR ALS 2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0434 | PR SPECIALTY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0435 | PR FIXED WING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0436 | PR ROTARY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0888 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0998 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A0999 | PR UNLISTED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A2022 | INNOVABURN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A2023 | INNOVAMATRIX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A2024 | RESOLVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A2025 | MIRO3D, PER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4206 | 1 CC STERILE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4207 | PR 2 CC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4208 | PR 3 CC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4209 | PR 5+ CC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4211 | PR SUPP FOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4212 | PR NON NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4213 | PR 20+ CC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4215 | PR STERILE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4216 | PR STERILE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4217 | PR STERILE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4220 | PR INFUSION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4221 | PR MAINT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4222 | PR INFUSION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4223 | PR INFUSION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4224 | PR SUPPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4225 | PR SUP/EXT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4230 | PR INFUS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4231 | PR INFUSION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4232 | PR SYRINGE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4233 | PR ALKALIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4234 | PR J-CELL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4235 | PR LITHIUM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4236 | PR SILVR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4238 | SUPPLY NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4239 | PR SUPPLY NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4244 | PR ALCOHOL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4245 | PR ALCOHOL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4246 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4247 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4248 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4250 | PR URINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4252 | BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4253 | PR BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4256 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4258 | PR LANCET NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4259 | PR LANCETS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4263 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4264 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK C, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4265 | PR PARAFFIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4280 | PR BRST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4281 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4282 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4283 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4284 | PR REPLCMNT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4285 | PR REPLCMNT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4286 | PR REPLCMNT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4290 | PR SACRAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4300 | PR CATH IMPL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4301 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4305 | PR DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4306 | PR DRUG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4310 | PR INSERT NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4311 | PR CATHETER NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4312 | PR CATH W/O NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4313 | PR CATHETER NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4314 | PR CATH NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4315 | PR CATH NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4316 | PR CATH NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4320 | PR IRRIGATION NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4321 | PR CATH NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4322 | PR IRRIGATION NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4326 | PR MALE NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4327 | PR FEM NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4328 | PR FEM NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4330 | PR STOOL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4331 | PR EXTENSION NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4332 | PR LUBE NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4333 | PR URINARY NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4334 | PR URINARY NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4335 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4337 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4338 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4340 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4344 | PR CATH INDW NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4346 | PR CATH INDW NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4349 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4351 | PR STRAIGHT NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4352 | PR COUDE TIP NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4353 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4354 | PR CATH NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4355 | PR BLADDER NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4356 | PR EXT URETH NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4357 | PR BEDSIDE NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4358 | PR URINARY NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4359 | PR URINARY NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4360 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4361 | PR OSTOMY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4362 | PR SOLID SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4363 | PR OSTOMY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4364 | PR ADHESIVE, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4365 | PR ADHESIVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4366 | PR OSTOMY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4367 | PR OSTOMY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4368 | PR OSTOMY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4369 | PR SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4371 | PR SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4372 | PR SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4373 | PR SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4375 | PR DRAINABLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4376 | PR DRAINABLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4377 | PR DRAINABLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4378 | PR DRAINABLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4379 | PR URINARY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4380 | PR URINARY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4381 | PR URINARY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4382 | PR URINARY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4383 | PR URINARY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4384 | PR OSTOMY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4385 | PR OST SKN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4387 | PR OST CLSD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4388 | PR DRAINABLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4389 | PR DRAINABLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4390 | PR DRAINABLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4391 | PR URINARY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4392 | PR URINARY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4393 | PR URINE PCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4394 | PR OSTOMY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4395 | PR OSTOMY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4396 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4398 | PR OSTOMY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4399 | PR OSTOMY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4400 | PR OSTOMY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4402 | PR LUBRICANT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4404 | PR OSTOMY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4405 | PR NONPECTIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4406 | PR PECTIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4407 | PR EXT WEAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4408 | PR EXT WEAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4409 | PR OST SKN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4410 | PR OST SKN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4411 | PR OST SKN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4412 | PR OST POUCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4413 | PR 2 PC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4414 | PR OST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4415 | PR OST SKN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4416 | PR OST PCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4417 | PR OST PCH W NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4418 | PR OST PCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4419 | PR OST PCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4420 | PR OST PCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4421 | PR OSTOMY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4422 | PR OST POUCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4423 | PR OST PCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4424 | PR OST PCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4425 | PR OST PCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4426 | PR OST PCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4427 | PR OST PCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4428 | PR URINE OST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4429 | PR URINE OST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4430 | PR OST URINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4431 | PR OST PCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4432 | PR OS PCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4433 | PR URINE OST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4434 | PR OST PCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4436 | PR IRR SUPPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4437 | PR IRR SUPPLY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4450 | PR NON- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4452 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4453 | PR REC CATH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4455 | PR ADHESIVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4456 | PR ADHESIVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4461 | PR SURGICL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4465 | PR NON- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4467 | PR BELT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4481 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4483 | PR MOISTURE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4490 | PR ABOVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4495 | PR THIGH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4500 | PR BELOW NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4510 | PR FULL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4554 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4556 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4557 | PR LEAD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4558 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4560 | NEUROMUSCU AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4561 | PR PESSARY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4562 | PR PESSARY, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4565 | PR SLINGS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4566 | PR SHOULD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4570 | PR SPLINT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4595 | PR TENS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4600 | PR SLEEVE, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4601 | PR LITH ION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4605 | PR TRACH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4606 | PR OXYGEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4611 | PR HEAVY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4612 | PR BATTERY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4613 | PR BATTERY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4614 | PR HAND-HELD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4615 | CANNULA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4616 | TUBING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4617 | MOUTH PIECE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4618 | PR BREATHING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4619 | PR FACE TENT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4620 | VARIABLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4623 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4624 | PR TRACHEAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4627 | PR SPACER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4628 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4629 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4630 | PR REPL BAT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4635 | PR UNDERARM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4636 | PR HANDGRIP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4637 | PR REPL TIP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4640 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4649 | PR SURGICAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4651 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4652 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4657 | PR SYRINGE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4660 | PR SPHYG/BP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4663 | PR DIALYSIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4670 | PR AUTOMATIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4680 | PR ACTIVATED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4690 | PR DIALYZER, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4706 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4707 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4708 | PR ACETATE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4709 | PR ACID CONC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4714 | PR TREATED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4719 | PR Y SET AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4720 | PR DIALYSAT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4721 | PR DIALYSAT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4722 | PR DIALYS SOL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4723 | PR DIALYS SOL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4724 | PR DIALYS SOL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4725 | PR DIALYS SOL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4726 | PR DIALYS SOL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4730 | PR FISTULA AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4736 | PR TOPICAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4737 | PR INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4740 | PR SHUNT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4750 | PR ART OR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4755 | PR COMB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4760 | PR DIALYSATE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4765 | PR DIALYSATE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4766 | PR DIALYSATE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4772 | PR BLOOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4773 | PR OCCULT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4774 | PR AMMONIA AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4802 | PR PROTAMINE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4860 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4911 | PR DRAIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4913 | PR MISC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4918 | PR VENOUS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4927 | PR NON- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4928 | PR SURGICAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4929 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4930 | PR STERILE, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4931 | PR REUSABLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A4932 | PR REUSABLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5051 | PR POUCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5052 | PR CLSD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5053 | PR CLSD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5054 | PR CLSD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5055 | PR STOMA CAP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5056 | PR 1 PC OST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5057 | PR 1 PC OST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5061 | PR POUCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5062 | PR DRNBLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5063 | PR DRAIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5071 | PR URINARY NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5072 | PR URINARY NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5073 | PR URINARY NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5081 | PR CONTINENT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5082 | PR CONTINENT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5083 | STOMA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5093 | PR OSTOMY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5102 | PR BEDSIDE NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5105 | URINARY NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5112 | PR URINARY NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5113 | PR LATEX LEG NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5114 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5120 | PR SKIN NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5121 | PR SOLID SKIN NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5122 | PR SOLID SKIN NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5126 | PR DISK/FOAM NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5131 | PR APPLIANCE NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5200 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5500 | PR DIAB SHOE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5501 | PR DIABETIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5503 | PR DIABETIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5504 | PR DIABETIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5505 | PR DIAB SHOE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5506 | PR DIABETIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A5507 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6010 | PR COLLAGEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6011 | PR COLLAGEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6021 | PR COLLAGEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6022 | PR COLLAGEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6023 | PR COLLAGEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6024 | PR COLLAGEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6025 | PR SILICONE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6154 | PR WOUND NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6196 | PR ALGINATE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6197 | PR ALGINATE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6198 | PR ALGINATE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6199 | PR ALGINATE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6203 | PR COMPOSITE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6204 | PR COMPOSITE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6205 | PR COMPOSITE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6206 | PR CONTACT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6207 | PR CONTACT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6208 | PR CONTACT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6209 | PR FOAM DRSG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6210 | PR FOAM DRG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6211 | PR FOAM DRG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6212 | PR FOAM DRG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6213 | PR FOAM DRG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6214 | PR FOAM DRG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6215 | PR FOAM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6216 | PR NON- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6217 | PR NON- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6218 | PR NON- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6219 | PR GAUZE <= NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6220 | PR GAUZE >16 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6221 | PR GAUZE > 48 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6222 | PR GAUZE <=16 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6223 | PR GAUZE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6224 | PR GAUZE > 48 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6228 | PR GAUZE <= NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6229 | PR GAUZE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6230 | PR GAUZE > 48 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6231 | PR HYDROGEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6232 | PR HYDROGEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6233 | PR HYDROGEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6234 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6235 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6236 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6237 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6238 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6239 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6240 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6241 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6242 | PR HYDROGEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6243 | PR HYDROGEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6244 | PR HYDROGEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6245 | PR HYDROGEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6246 | PR HYDROGEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6247 | PR HYDROGEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6248 | PR HYDROGEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6250 | PR SKIN SEAL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6251 | PR ABSORPT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6252 | PR ABSORPT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6253 | PR ABSORPT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6254 | PR ABSORPT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6255 | PR ABSORPT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6256 | PR ABSORPT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6257 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6258 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6259 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6260 | PR WOUND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6261 | PR WOUND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6262 | PR WOUND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6266 | PR IMPREG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6402 | PR STERILE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6403 | PR STERILE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6404 | PR STERILE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6407 | PR PACKING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6410 | PR STERILE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6411 | PR NON- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6412 | PR OCCLUSIVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6441 | PR PAD BAND NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6442 | PR CONFORM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6443 | PR CONFORM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6444 | PR CONFORM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6445 | PR CONFORM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6446 | PR CONFORM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6447 | PR CONFORM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6448 | PR LT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6449 | PR LT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6450 | PR LT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6451 | PR MOD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6452 | PR HIGH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6453 | PR SELF- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6454 | PR SELF- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6455 | PR SELF- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6456 | PR ZINC PASTE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6457 | PR TUBULAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6501 | PR COMPRES AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6502 | PR COMPRES AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6503 | PR COMPRES AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6504 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6505 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6506 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6507 | PR CMPRS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6508 | PR CMPRS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6509 | PR COMPRES AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6510 | PR COMPRES AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6511 | PR COMPRES AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6512 | PR COMPRES AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6513 | PR COMPRESS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6530 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6531 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6532 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6533 | PR GC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6534 | PR GC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6535 | PR GC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6536 | PR GC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6537 | PR GC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6538 | PR GC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6539 | PR GC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6540 | PR GC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6541 | PR GC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6542 | PR GC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6543 | PR GC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6544 | PR GC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6545 | PR GRAD COM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6549 | PR G AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A6550 | PR NEG PRES NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7000 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7002 | PR TUBING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7003 | PR NEBULIZER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7004 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7005 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7006 | PR FILTERED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7007 | PR LG VOL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7009 | PR NEBULIZER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7010 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7011 | PR NONDISPOS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7012 | PR NEBULIZER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7013 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7014 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7015 | PR AEROSOL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7016 | PR NEBULIZER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7017 | PR NEBULIZER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7018 | PR WATER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7025 | PR REPLACE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7026 | PR REPLACE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7027 | COMBINATION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7028 | REPL ORAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7029 | REPL NASAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7030 | PR CPAP FULL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7031 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7032 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7033 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7034 | PR NASAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7035 | PR POS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7036 | PR POS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7037 | PR POS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7038 | PR POS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7039 | PR FILTER, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7046 | PR REPL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7520 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7521 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7522 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7523 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7525 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A7526 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A8000 | PR SOFT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A8001 | PR HARD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A8002 | PR SOFT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A8003 | PR HARD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A8004 | PR REPL SOFT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A9268 | PROGRAMMER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A9269 | PROGRAMABLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A9272 | PR DISP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A9273 | PR HOT/COLD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A9274 | EXT AMB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A9275 | PR DISP HOME NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A9276 | DISPOSABLE NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A9277 | PR EXTERNAL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A9278 | EXTERNAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A9279 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A9284 | PR NON- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A9292 | PRESCRIPTION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A9507 | PR IN111 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A9513 | PR LUTETIUM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A9542 | PR IN111 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A9573 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A9589 | PR INSTI AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A9590 | PR IODINE I-131 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A9600 | PR SR89 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A9697 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| A9900 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4034 | ENTER FEED NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4035 | PR ENTERAL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4036 | PR ENTERAL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4081 | PR ENTERAL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4082 | PR ENTERAL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4083 | PR ENTERAL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4087 | GASTRO/JEJUN NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4088 | GASTRO/JEJUN NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4100 | PR FOOD NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4103 | PR EF PED NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4104 | PR ADDITIVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4105 | PR ENZYME AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4148 | ENTERAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK,CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4149 | PR EF NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4150 | PR EF NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4151 | DELETED 2088 NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4152 | PR EF CALORIE NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4153 | PR EF NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4154 | PR EF SPEC NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4155 | PR EF NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4156 | DELETED 2089 NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4157 | PR EF SPECIAL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4158 | PR EF PED NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4159 | PR EF PED NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4160 | PR EF PED NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4161 | PR EF PED NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4162 | PR EF PED NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4164 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4168 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4172 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4176 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4178 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4180 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4185 | PR PN SOLN NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4189 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4193 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4197 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4199 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4216 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4220 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4222 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B4224 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B5000 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B5100 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B5200 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B9002 | PR ENTERAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B9004 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B9006 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B9998 | PR ENTERAL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| B9999 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C1789 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C1840 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C1883 | PR ADAPT/EXT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C1897 | PR LEAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9088 | PR INSTILL, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9145 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9147 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9150 | XENON XE-129 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9152 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9153 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9154 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9155 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9156 | FLOTUFOLAST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9157 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9158 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9163 | INJ NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9164 | CANTHARIDIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9165 | INJ, NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9250 | PR ARTISS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9507 | FRESH FROZEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9739 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9740 | PR CYSTO IMPL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9772 | PR REVASC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9773 | PR REVASC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9774 | PR REVASC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9775 | PR REVASC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9784 | GASTRIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9785 | ENDOSCOPIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9786 | ECHOCARDIOG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 9/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9787 | GASTRIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9788 | OPTO- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9789 | INSTILLATION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9790 | HISTOTRIPSY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9791 | MAGNETIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9792 | BLINDED OR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9800 | PR DERMAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| C9803 | PR HOPD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 5/12/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0100 | PR CANE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0105 | PR CANE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0110 | PR CRUTCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0111 | PR CRUTCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0112 | PR CRUTCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0113 | PR CRUTCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0114 | PR CRUTCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0116 | PR CRUTCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0117 | PR UNDERARM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0118 | PR CRUTCH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0130 | PR WALKER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0135 | PR WALKER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0140 | PR WALKER W NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0141 | PR RIGID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0143 | PR WALKER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0144 | ENCLOSED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0147 | PR WALKER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0148 | PR HEAVYDUTY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0149 | PR HEAVY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0153 | PR FOREARM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0154 | PR WALKER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0155 | PR WALKER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0157 | PR WALKER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0158 | PR WALKER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0159 | PR BRAKE FOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0160 | PR SITZ TYPE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0161 | PR SITZ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0162 | PR SITZ BATH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0163 | PR COMMODE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0164 | PR COMMODE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0165 | PR COMMODE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0166 | PR COMMODE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0167 | PR COMMODE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0168 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0169 | DELETED 2272 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0170 | PR COMMODE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0171 | PR COMMODE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0172 | PR SEAT LIFT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0175 | PR COMMODE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0181 | PR PRESS PAD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0182 | PR REPLACE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0183 | POWERED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0184 | PR DRY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0185 | PR GEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0186 | PR AIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0187 | PR WATER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0188 | PR SYNTHETIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0189 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0190 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0191 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0193 | PR POWERED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0194 | PR AIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0196 | PR GEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0197 | PR AIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0198 | PR WATER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0199 | PR DRY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0202 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0210 | PR ELECTRIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0217 | PR WATER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0218 | PR FLUID CIRC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0225 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0235 | PR PARAFFIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0236 | PR PUMP FOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0240 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0243 | PR TOILET RAIL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0244 | PR TOILET NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0245 | PR TUB STOOL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0246 | PR TRANSFER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0247 | PR TRANS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0248 | PR HDTRANS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0250 | PR HOSP BED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0255 | PR HOSPITAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0260 | PR HOSP BED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0265 | PR HOSP BED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0271 | PR MATTRESS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0275 | PR BED PAN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0276 | PR BED PAN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0277 | PR POWERED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0280 | PR BED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0300 | PR ENCLOSED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0303 | PR HOSP BED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0304 | PR HOSP BED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0305 | PR RAILS BED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0310 | PR RAILS BED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0315 | PR BED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0316 | PR BED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0325 | PR URINAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0326 | PR URINAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0328 | PR PED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0329 | PR PED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0350 | PR CONTROL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0352 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0370 | PR AIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0371 | PR NONPOWER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0372 | PR POWERED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0373 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0424 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0431 | PR PORTABLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0433 | PR PORTABLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0434 | PR PORTABLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0439 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0441 | PR OXYGEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0442 | PR OXYGEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0443 | PR PORTABLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0444 | PR PORTABLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0445 | PR OXIMETER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0447 | PR PORT O2 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0457 | PR CHEST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0459 | PR CHEST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0465 | PR HOME VENT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0466 | PR HOME VENT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0467 | PR HOME VENT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0470 | PR RAD W/O AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0471 | PR RAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0472 | PR RAD W AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0480 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0482 | PR COUGH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0483 | PR HIGH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0490 | POWER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0491 | ORAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0500 | PR IPPB ALL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0530 | ELECTRONIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0550 | PR HUMIDIF AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0561 | PR HUMIDIFIER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0562 | PR HUMIDIFIER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0565 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0570 | PR NEBULIZER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0574 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0575 | PR NEBULIZER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0580 | PR NEBULIZER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0585 | PR NEBULIZER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0600 | PR SUCTION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0601 | PR CONT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0602 | PR MANUAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0603 | PR ELECTRIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0604 | HOSP GRADE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0606 | PR DRAINAGE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0610 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0615 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0616 | PR CARDIAC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0617 | PR AUTOMATIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0618 | PR APNEA AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0619 | PR APNEA AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0621 | PR PATIENT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0625 | PR PATIENT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0627 | PR SEAT LIFT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0628 | PR SEAT LIFT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0629 | PR SEAT LIFT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0630 | PATIENT LIFT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0635 | PR PATIENT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0637 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0638 | PR STANDING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0641 | PR MULTI- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0642 | PR DYNAMIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0650 | PR PNEUMA AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0651 | PR PNEUM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0652 | PR PNEUM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0655 | PR PNEUMATIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0660 | PR PNEUMATIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0665 | PR PNEUMATIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0666 | PR PNEUMATIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0667 | PR SEG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0668 | PR SEG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0669 | PR SEG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0670 | PR SEG PNEUM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0671 | PR PRESSURE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0672 | PR PRESSURE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0673 | PR PRESSURE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0676 | PR INTER LIMB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0700 | PR SAFETY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0701 | PR HELMET W NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0705 | TRANSFER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0710 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0711 | UPPER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0720 | PR TENS TWO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0730 | PR TENS FOUR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0731 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0740 | PR NON- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0745 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0747 | PR ELEC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0748 | PR ELEC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0760 | PR OSTEOGEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0762 | PR TRANS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0764 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0776 | PR IV POLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0779 | PR AMB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0780 | PR MECH AMB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0781 | PR EXTERNAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0782 | PR NON- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0783 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0784 | PR EXT AMB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0786 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0787 | PR CGS DOSE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0791 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0840 | PR TRACT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0850 | PR TRACTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0855 | PR CERVICAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0856 | PR CERVIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0860 | PR TRACT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0880 | PR TRAC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0900 | PR TRAC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0910 | PR TRAPEZE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0911 | PR HD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0912 | PR HD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0920 | PR FRACTURE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0930 | PR FRACTURE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0935 | PR CONT PAS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0940 | PR TRAPEZE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0941 | PR GRAVITY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0942 | PR CERVICAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0945 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0946 | PR FRACTURE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0950 | PR TRAY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0951 | PR LOOP HEEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0952 | PR TOE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0953 | PR W/C NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0954 | PR FOOT BOX, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0955 | PR CUSHIONED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0956 | PR W/C NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0957 | PR W/C MEDIAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0958 | PR WHLCHR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0959 | PR AMPUTEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0960 | PR W/C NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0961 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0967 | PR MANUAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0969 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0970 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0971 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0972 | DELETED 2294 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0973 | PR W/CH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0974 | PR W/CH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0977 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0978 | PR W/C NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0980 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0981 | PR SEAT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0982 | PR BACK NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0986 | PR MAN W/C AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0990 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0992 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0994 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E0995 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1002 | PR PWR SEAT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1003 | PR PWR SEAT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1004 | PR PWR SEAT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1005 | PR PWR SEAT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1006 | PR PWR SEAT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1007 | PR PWR SEAT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1008 | PR PWR SEAT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1009 | PR ADD MECH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1010 | PR ADD PWR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1011 | PR PED WC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1012 | PR CTR MOUNT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1013 | DELETED 2304 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1014 | PR RECLINING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1015 | PR SHOCK NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1016 | PR SHOCK NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1017 | PR HD SHCK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1018 | PR HD SHCK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1020 | PR RESIDUAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1028 | PR W/C NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1029 | PR W/C VENT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1031 | PR ROLLABOUT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1035 | PR PATIENT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1050 | PR WHELCHR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1060 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1070 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1083 | PR HEMI- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1084 | PR HEMI- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1085 | PR HEMI- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1086 | PR HEMI- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1087 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1088 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1089 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1090 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1092 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1093 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1100 | PR WHCHR S- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1110 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1130 | PR WHLCHR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1140 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1150 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1160 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1161 | PR MANUAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1170 | PR WHLCHR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1171 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1172 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1180 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1190 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1195 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1200 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1210 | DELETED 2314 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1211 | DELETED 2315 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1212 | DELETED 2316 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1213 | DELETED 2317 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1220 | PR WHLCHR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1225 | PR MANUAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1226 | PR MANUAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1229 | PR PEDIATRIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1230 | PR POWER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1231 | PR RIGID PED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1232 | PR FOLDING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1233 | PR RIG PED WC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1234 | PR FLD PED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1235 | PR RIGID PED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1236 | PR FOLDING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1237 | PR RGD PED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1238 | PR FLD PED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1239 | PR PED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1240 | PR WHCHR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1250 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1260 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1270 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1280 | PR WHCHR H- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1285 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1290 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1295 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1296 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1297 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1298 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1300 | PR WHIRLPOOL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1310 | PR WHIRLPOOL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1353 | PR OXYGEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1355 | PR OXYGEN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1372 | PR OXY SUPPL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1390 | PR OXYGEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1399 | PR DURABLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1510 | PR KIDNEY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1520 | PR HEPARIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1530 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1540 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1550 | PR BATH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1560 | PR REPLACE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1570 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1575 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1580 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1590 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1592 | PR AUTO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1594 | PR CYCLER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1600 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1620 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1629 | PR TABLO FOR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1630 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1632 | PR WEARABLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1635 | PR COMPACT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1637 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1639 | PR SCALE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1699 | PR DIALYSIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1700 | PR JAW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1701 | PR REPL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1702 | PR REPL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1800 | PR ADJUST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1801 | SPS ELBOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1802 | PR ADJST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1805 | PR ADJUST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1806 | SPS WRIST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1810 | PR ADJUST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1811 | SPS KNEE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1812 | PR KNEE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1815 | PR ADJUST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1816 | SPS ANKLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1818 | SPS FOREARM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1820 | PR SOFT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1821 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1825 | PR ADJUST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1830 | PR ADJUST TOE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1831 | PR STATIC STR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1840 | PR ADJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E1841 | STATIC STR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2100 | PR BLD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2101 | PR BLD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2102 | ADJUNCTIVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2103 | PR NON- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2201 | PR MAN W/CH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2202 | PR SEAT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2203 | PR FRAME AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2204 | PR FRAME AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2205 | PR MANUAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2206 | PR MAN WC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2207 | PR CRUTCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2208 | PR CYLINDER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2209 | PR ARM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2210 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2211 | PR PNEUMATIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2212 | PR PNEUMATIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2213 | PR PNEUMATIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2214 | PR PNEUMATIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2215 | PR PNEUMATIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2216 | PR FOAM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2217 | PR FOAM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2218 | PR FOAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2219 | PR FOAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2220 | PR SOLID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2221 | PR SOLID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2222 | PR SOLID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2223 | PR VALVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2224 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2225 | PR CASTER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2226 | PR CASTER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2227 | GEAR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2228 | MWC ACC, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2291 | PR PLANAR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2292 | PR PLANAR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2293 | PR CONTOUR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2294 | PR CONTOUR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2300 | PR PWR SEAT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2310 | PR ELECTRO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2311 | PR ELECTRO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2312 | MINI-PROP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2313 | PWC HARNESS, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2321 | PR HAND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2323 | PR SPECIAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2324 | PR CHIN CUP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2325 | PR SIP AND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2326 | PR BREATH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2327 | PR HEAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2328 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2329 | PR HEAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2330 | PR HEAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2340 | PR W/C WDTH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2341 | PR W/C WDTH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2342 | PR W/C DPTH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2343 | PR W/C DPTH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2351 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2359 | PR GR34 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2361 | PR 22NF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2363 | PR GR24 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2366 | PR BATTERY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2368 | PR PWR WC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2369 | PR PWR WC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2370 | PR PWR WC DR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2371 | PR GR27 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2373 | HAND/CHIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2374 | PR HAND/CHIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2375 | PR NON- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2376 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2377 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2378 | PR PW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2381 | PR PNEUM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2382 | PR TUBE, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2383 | PR INSERT, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2384 | PR PNEUMATIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2385 | PR TUBE, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2386 | PR FOAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2387 | PR FOAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2388 | PR FOAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2389 | PR FOAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2390 | PR SOLID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2391 | PR SOLID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2392 | PR SOLID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2393 | PR VALVE, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2394 | PR DRIVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2395 | PR CASTER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2396 | PR CASTER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2402 | PR NEG PRESS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2500 | PR SGD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2502 | PR SGD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2504 | PR SGD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2506 | PR SGD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2508 | PR SGD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2510 | PR SGD W AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2511 | PR SGD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2512 | PR SGD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2599 | PR SGD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2601 | PR GEN W/C NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2602 | PR GEN W/C AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2603 | PR SKIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2604 | PR SKIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2605 | PR POSITION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2606 | PR POSITION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2607 | PR SKIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2608 | PR SKIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2609 | PR CUSTOM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2611 | PR GEN USE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2612 | PR GEN USE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2613 | PR POSITION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2614 | PR POSITION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2615 | PR POS BACK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2616 | PR POS BACK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2617 | PR CUSTOM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2619 | PR REPLACE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2620 | PR WC PLANAR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2621 | PR WC PLANAR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2622 | PR ADJ SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2623 | PR ADJ SKIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2624 | PR ADJ SKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2625 | PR ADJ SKIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2626 | PR SEO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2627 | PR ARM SUPP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2628 | PR MOBILE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2629 | PR FRICTION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2630 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2631 | PR ELEVAT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2632 | PR OFFSET/LAT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E2633 | PR MOBILE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| E8001 | PR UPRIGHT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0011 | HIV PREP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0012 | INJECTION OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0013 | HIV PREP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0104 | PR CA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0108 | PR DIAB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0109 | PR DIAB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0117 | PR GLAUCOMA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0118 | PR GLAUCOMA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0121 | PR COLON CA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0127 | PR TRIM NAIL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0156 | PR HHCP-SVS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0162 | PR HHC RN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0182 | PR HOSPICE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0245 | PR INITIAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0246 | PR FOLLOWUP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0247 | PR ROUTINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0279 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0299 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0300 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0315 | IMMUNIZATION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 5/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0328 | PR FECAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0337 | PR HOSPICE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0398 | PR HOME AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/6/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0399 | PR HOME AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/6/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0400 | PR HOME AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/6/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0429 | PR DERMAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0466 | PR FQHC VISIT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 5/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0467 | PR FQHC VISIT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 5/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0468 | PR FQHC VISIT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 5/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0469 | PR FQHC VISIT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 5/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0470 | PR FQHC VISIT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, 5/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G0495 | PR RN CARE AUTHORIZATION REQUIRED USE OF PCS AND CFC IS CLINICAL INFORMATION SK, STAR C, CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G2011 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G2022 | PR BENEF AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G2214 | PR INIT/SUB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G3002 | PR CHRONIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G3003 | PR EA ADDL 15 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| G9012 | PR OTHER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK C, CP 9/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H0001 | PR ALCOHOL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H0004 | PR ALCOHOL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H0005 | PR ALCOHOL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H0012 | PR ALCOHOL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H0015 | PR ALCOHOL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H0016 | PR ALCOHOL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H0020 | PR ALCOHOL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H0031 | PR MH HEALTH NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H0033 | PR ORAL MED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H0034 | PR MED TRNG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H0035 | PR MH PARTIAL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H0038 | PR SELF- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H0047 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H0049 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H0050 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H2011 | PR CRISIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H2012 | PR BEHAV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H2014 | PR SKILLS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H2017 | PR PSYSOC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H2023 | PR AUTHORIZATION REQUIRED USE OF LTSS IS IDENTIFIED CLINICAL INFORMATION SK S, C, CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H2025 | PR SUPP MAINT AUTHORIZATION REQUIRED USE OF LTSS IS IDENTIFIED CLINICAL INFORMATION SK S, C, CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H2035 | PR A/D TX NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H2040 | COORDINATED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| H2041 | COORDINATED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0121 | PR INJ., AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0122 | PR INJ., AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0129 | PR ABATACEPT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0130 | PR ABCIXIMAB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0131 | TO , 10 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0135 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0137 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0172 | PR INJ, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0174 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0178 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0179 | PR INJ, AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0180 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0184 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0185 | PR INJ., NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0206 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0208 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0216 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0217 | INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0218 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0219 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0221 | PR LUMIZYME AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0222 | PR INJ., AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0223 | PR INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0224 | PR INJ. AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0225 | PR INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0248 | INJECTION, NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, 3/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0291 | PR INJ., AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0349 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0402 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0457 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0480 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0490 | PR BELIMUMAB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0491 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0517 | PR INJ., AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0567 | PR INJ., AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0570 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0584 | PR INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0585 | PR INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0586 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0587 | PR INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0588 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0593 | PR INJ., AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0596 | PR INJECTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0597 | PR C-1 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0598 | PR C-1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0599 | PR INJ., NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0600 | PR EDETATE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0606 | PR INJ, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0612 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0613 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0665 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0691 | PR INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0699 | PR INJ, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0706 | PR CAFFEINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0713 | PR INJ AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0716 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0735 | PR CLONIDINE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0736 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0737 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0739 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0741 | PR INJ, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0742 | PR INJ IMIP 4 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0791 | PR INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0801 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0802 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0841 | PR INJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0850 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0874 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0877 | PR INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0878 | TO , 1 MG COVERED SERVICE BUT DHP | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0881 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0882 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0885 | PR EPOETIN NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0888 | PR EPOETIN NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0889 | DAPRODUSTAT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0895 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J0896 | PR INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1050 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK C, CP | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1095 | PR INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1096 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1100 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1105 | INJ, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1200 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1201 | PR INJ. AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1290 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1300 | ECULIZUMAB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1302 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1303 | PR INJ., AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1305 | PR INJ, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1306 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1322 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1411 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1412 | INJ, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1413 | INJ ROCTAVIAN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1426 | PR INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1427 | PR INJ. AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1428 | PR INJ, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1429 | INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1437 | PR INJ. FE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1439 | PR INJ FERRIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1440 | PR FILGRASTIM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1442 | PR INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1448 | PR INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1449 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1453 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1455 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1458 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1459 | PR INJ IVIG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1551 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1554 | PR INJ. AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1558 | PR INJ. AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1569 | GAMMAGARD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1570 | TO , 500 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1571 | HEPAGAM B IM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1573 | HEPAGAM B NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1574 | PR INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1576 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1602 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1632 | PR INJ., AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1640 | PR HEMIN, 1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1642 | PR INJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1720 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1726 | PR MAKENA, 10 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1729 | PR INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1738 | PR INJ. AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1743 | IDURSULFASE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1744 | PR ICATIBANT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 8/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1745 | PR INFLIXIMAB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1747 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1750 | PR INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1756 | PR IRON NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1786 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1805 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1806 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1811 | INSULIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1812 | INSULIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1813 | INSULIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1814 | INSULIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1815 | PR INSULIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1817 | PR INSULIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1820 | TO , 5 MG | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1823 | PR INJ. AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1826 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1836 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1920 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1921 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 9/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1931 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1932 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1941 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1943 | PR INJ., AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1944 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1950 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1951 | PR INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1952 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1954 | PR INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J1961 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2020 | PR LINEZOLID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2182 | PR INJECTION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2249 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2250 | PR INJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2305 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2315 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2326 | PR INJ, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2329 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2356 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2357 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2359 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2371 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2372 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2405 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2406 | PR INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2427 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2469 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2503 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2506 | PR INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2507 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2508 | INJ, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2561 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2597 | PR INJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2598 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2599 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2724 | PROTEIN C AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2777 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2778 | RANIBIZUMAB AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2779 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2781 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2786 | PR INJECTION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2788 | PR RHO D NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2790 | PR RHO D NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2791 | RHOPHYLAC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2792 | PR RHO(D) NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2793 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2798 | PR INJ., AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2799 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2805 | TO , 5 COVERED SERVICE BUT DHP | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2806 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2820 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2840 | PR INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2916 | PR NA FERRIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2997 | PR ALTEPLASE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J2998 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J3010 | PR FENTANYL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J3031 | PR INJ., AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J3032 | PR INJ. AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J3060 | PR INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J3111 | PR INJ. AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J3240 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J3241 | PR INJ. AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J3245 | PR INJ., AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J3262 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J3299 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J3300 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J3301 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J3316 | PR INJ., AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J3370 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J3380 | PR INJECTION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J3385 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J3396 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J3398 | PR INJ AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J3399 | PR INJ ONASE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J3401 | VYJUVEK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J3490 | PR DRUGS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J3590 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7100 | PR DEXTRAN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7110 | PR DEXTRAN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7168 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7169 | PR INJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7170 | PR INJ., AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7175 | PR INJ FACTOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7179 | PR VONVENDI AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7180 | PR FACTOR XIII AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7181 | PR FACTOR XIII AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7182 | PR FACTOR VIII AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7183 | PR WILATE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7185 | PR XYNTHA INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7186 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7187 | HUMATE-P, INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7188 | PR FACTOR VIII AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7189 | PR FACTOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7190 | PR FACTOR VIII AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7192 | PR FACTOR VIII AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7193 | PR FACTOR IX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7194 | PR FACTOR IX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7195 | PR FACTOR IX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7198 | PR ANTI- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7200 | PR FACTOR IX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7201 | PR FACTOR IX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7202 | PR FACTOR IX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7203 | PR FACTOR IX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7204 | PR INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7205 | PR FACTOR VIII AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7207 | PR FACTOR VIII AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7208 | PR INJ. JIVI 1 IU AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7209 | PR FACTOR VIII AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7210 | PR INJ, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7211 | PR INJ, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7212 | PR FACTOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7213 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 9/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7214 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7294 | PR SEG ACET NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK C, CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7295 | PR ETH ESTR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK C, CP 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7296 | PR KYLEENA, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK C, CP | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7297 | PR LILETTA 52 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK C, CP | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7298 | PR MIRENA 52 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK C, CP | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7300 | PR INTRAUT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK C, CP | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7301 | PR SKYLA 13.5 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK C, CP | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7304 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK C, CP | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7307 | ETONOGESTRE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK C, CP | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7311 | PR INJ., AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7312 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7314 | PR INJ., YUTIQ, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7316 | PR INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7351 | PR INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7352 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7353 | ANACAULASE- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7402 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7504 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J7519 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J8499 | PR ORAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J8501 | PR ORAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9000 | PR DOXORUBIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9015 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9017 | PR ARSENIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9019 | PR ERWINAZE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9020 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9021 | PR INJ, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9022 | PR INJ, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9023 | PR INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9025 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9027 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9029 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9030 | PR BCG LIVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9031 | PR BCG LIVE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9035 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9036 | PR INJ. NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9037 | PR INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9039 | PR INJECTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9040 | PR BLEOMYCIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9041 | PR INJ., NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9042 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9043 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9044 | PR INJ, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9045 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9046 | PR INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9047 | PR INJECTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9050 | PR CARMUS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9051 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9055 | PR CETUXIMAB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9056 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9057 | PR INJ., NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9058 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9059 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9060 | PR CISPLATIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9061 | PR INJ, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9063 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9064 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9065 | PR INJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9070 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9071 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9072 | INJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9080 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9090 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9091 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9092 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9093 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9094 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9095 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9096 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9097 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9098 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9100 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9118 | PR INJ. NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9119 | PR INJ., AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9120 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9130 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9144 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9145 | PR INJECTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9150 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9151 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9153 | PR INJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9155 | PR DEGARELIX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9160 | PR DENILEUKIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9165 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9170 | PR DOCETAXEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9171 | PR DOCETAXEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9172 | DOCETAXEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9173 | PR INJ., NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9175 | PR ELLIOTTS B NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9176 | PR INJECTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9177 | PR INJ ENFORT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9178 | PR INJ, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9179 | PR ERIBULIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9181 | PR ETOPOSIDE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9182 | PR ETOPOSIDE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9185 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9190 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9196 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9198 | PR INJ. NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9199 | PR INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9200 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9201 | PR IN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9202 | PR GOSERELIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9204 | PR INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9205 | PR INJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9206 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9207 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9208 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9209 | PR MESNA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9210 | PR INJ., AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9211 | PR IDARUBICIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9214 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9216 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9217 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9218 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9223 | PR INJ. NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9225 | VANTAS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9226 | SUPPRELIN LA AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9227 | PR INJ. AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9228 | PR IPILIMUMAB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9229 | PR INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9230 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9245 | PR INJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9246 | PR INJ., NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9247 | PR INJ, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9250 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9255 | INJ, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9258 | PACLITAXEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9259 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9260 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9261 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9262 | PR INJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9263 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9264 | TO , 1 MG DETERMINE MEDICAL NECESSITY | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9266 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9267 | PR PACLITAXEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9268 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9269 | PR INJ. NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9270 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9271 | PR INJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9272 | PR INJ, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9273 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9274 | INJECTION, NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9280 | PR MITOMYCIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9281 | PR MITOMYCIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9285 | PR INJ, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9286 | INJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9290 | PR MITOMYCIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9291 | PR MITOMYCIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9293 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9294 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9295 | PR INJECTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9296 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9297 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9298 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9299 | PR INJECTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9300 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9301 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9302 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9303 | PANITUMUMAB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9304 | PR INJ. NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9305 | TO , 10 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9306 | PR INJECTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9307 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9308 | PR INJECTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9309 | PR INJ, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9310 | PR RITUXIMAB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9311 | PR INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9312 | PR INJ., AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9313 | PR INJ., AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9314 | PR INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9316 | PR PERTUZU, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9317 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9318 | PR INJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9319 | PR INJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9320 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9321 | INJECTION, NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9322 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9323 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9324 | INJ, PEMRYDI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9325 | PR INJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9328 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9330 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9331 | INJECTION, NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9332 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9333 | INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9334 | INJ EFGART- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9340 | PR THIOTEPA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9345 | INJECTION, NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9347 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9348 | PR INJ. NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9349 | PR INJ., NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9350 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9351 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9352 | PR INJECTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9353 | PR INJ. NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9354 | PR INJ ADO- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9355 | PR INJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9356 | PR INJ. NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9357 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9358 | INJ FAM- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9359 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9360 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9370 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9371 | PR INJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9380 | INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9381 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9390 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9393 | PR INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9394 | PR INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9395 | TO , 25 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9400 | PR INJ ZIV- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9600 | PR PORFIMER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| J9999 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0001 | PR STANDARD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0002 | PR STND HEMI AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0003 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0004 | PR HIGH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0005 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0006 | PR HEAVY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0007 | PR EXTRA AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0008 | PR CSTM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0009 | PR OTHER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0010 | PR STND WT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0011 | PR STND WT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0012 | PR LTWT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0013 | PR CUSTOM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0015 | PR DETACH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0017 | PR DETACH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0018 | PR DETACH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0019 | PR ARM PAD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0020 | PR FIXED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0023 | DELETED 2474 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0024 | DELETED 2475 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0037 | PR HI MOUNT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0038 | PR LEG STRAP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0039 | PR LEG STRAP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0040 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0041 | PR LARGE SIZE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0042 | PR STANDARD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0043 | PR FTRST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0044 | PR FTRST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0045 | PR FOOTREST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0046 | PR ELEVAT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0047 | PR ELEVAT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0050 | PR RATCHET NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0051 | PR CAM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0052 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0053 | PR ELEVATE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0056 | PR SEAT HT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0059 | DELETED 2494 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0060 | DELETED 2495 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0061 | DELETED 2496 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0064 | DELETED 2499 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0065 | PR SPOKE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0066 | DELETED 2500 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0067 | DELETED 2501 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0068 | DELETED 2502 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0069 | PR REAR WHL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0070 | PR REAR WHL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0071 | PR FRONT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0072 | PR FRNT CSTR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0073 | PR CASTER PIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0074 | DELETED 2503 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0075 | DELETED 2504 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0076 | DELETED 2505 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0077 | PR FRONT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0078 | DELETED 2506 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0081 | DELETED 2509 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0090 | PR REAR TIRE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0091 | PR REAR TIRE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0092 | PR REAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0093 | PR REAR ZERO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0094 | PR WHEEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0095 | PR WHEEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0096 | PR WHEEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0097 | PR WHEEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0098 | PR DRIVE BELT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0099 | PR PWR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0108 | PR W/C AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0195 | PR ELEVATING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0455 | PR PUMP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0462 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0552 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0601 | PR REPL BATT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0602 | PR REPL BATT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0603 | PR REPL BATT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0604 | PR REPL BATT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0605 | PR REPL BATT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0606 | PR AED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0607 | PR REPL BATT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0609 | PR REPL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0672 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0730 | PR CTRL DOSE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0738 | PR PORTABLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0739 | PR REPAIR/SVC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0800 | PR POV GROUP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0801 | PR POV GROUP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0802 | PR POV GROUP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0813 | PR PWC GP 1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0814 | PR PWC GP 1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0815 | PR PWC GP 1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0816 | PR PWC GP 1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0820 | PR PWC GP 2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0821 | PR PWC GP 2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0822 | PR PWC GP 2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0823 | PR PWC GP 2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0824 | PR PWC GP 2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0825 | PR PWC GP 2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0826 | PR PWC GP 2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0827 | PR PWC GP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0828 | PR PWC GP 2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0829 | PR PWC GP 2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0835 | PR PWC GP2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0836 | PR PWC GP2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0837 | PR PWC GP 2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0838 | PR PWC GP 2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0839 | PR PWC GP2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0840 | PR PWC GP2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0841 | PR PWC GP2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0842 | PR PWC GP2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0843 | PR PWC GP2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0848 | PR PWC GP 3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0849 | PR PWC GP 3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0850 | PR PWC GP 3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0851 | PR PWC GP 3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0852 | PR PWC GP 3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0853 | PR PWC GP 3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0854 | PR PWC GP 3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0855 | PR PWC GP 3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0856 | PR PWC GP3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0857 | PR PWC GP3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0858 | PR PWC GP3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0859 | PR PWC GP3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0860 | PR PWC GP3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0861 | PR PWC GP3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0862 | PR PWC GP3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0863 | PR PWC GP3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0864 | PR PWC GP3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0868 | PR PWC GP 4 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0869 | PR PWC GP 4 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0870 | PR PWC GP 4 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0871 | PR PWC GP 4 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0877 | PR PWC GP4 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0878 | PR PWC GP4 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0879 | PR PWC GP4 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0880 | PR PWC GP4 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0884 | PR PWC GP4 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0885 | PR PWC GP4 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0886 | PR PWC GP4 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0890 | PR PWC GP5 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0891 | PR PWC GP5 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0898 | PR POWER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0899 | PR POW MOBIL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K0900 | PR CSTM DME AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K1022 | PR ENDOSKEL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K1030 | EXTERNAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 10/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| K1036 | SUPPLIES AND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0112 | PR CRANIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0113 | PR CRANIAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0120 | PR CERV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0130 | PR FLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0140 | PR CERVICAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0150 | PR CERV SEMI- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0160 | PR CERV SEMI- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0170 | PR CERVICAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0172 | PR CERV COL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0174 | PR CERV SR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0180 | PR CER POST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0190 | PR CERV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0200 | PR CERV COL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0220 | PR THOR RIB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0450 | PR TLSO FLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0452 | PR TLSO FLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0454 | PR TLSO TRNK NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0456 | PR TLSO FLEX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0458 | PR TLSO 2MOD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0460 | PR TLSO 2 SHL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0462 | PR TLSO 3MOD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0464 | PR TLSO 4MOD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0466 | PR TLSO R AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0468 | PR TLSO RIGID AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0470 | PR TLSO RIGID AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0472 | PR TLSO RIGID AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0480 | PR TLSO RIGID AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0482 | PR TLSO RIGID AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0484 | PR TLSO RIGID AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0486 | PR TLSO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0488 | PR TLSO RIGID AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0490 | PR TLSO RIGID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0491 | PR TLSO 2 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0492 | PR TLSO 3 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0621 | PR SIO FLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0622 | PR SIO FLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0623 | PR SIO PANEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0624 | PR SIO PANEL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0625 | PR LO FLEXIBL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0626 | PR LO SAG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0627 | PR LO SAGITT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0628 | PR LO FLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0629 | PR LSO FLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0630 | PR LSO POST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0631 | PR LSO SAG- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0632 | PR LSO SAG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0633 | PR LSO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0634 | PR LSO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0635 | PR LSO SAGIT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0636 | PR LSO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0637 | PR LSO SAG- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0638 | PR LSO SAG- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0639 | PR LSO S/C AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0640 | PR LSO S/C AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0700 | PR CTLSO A-P- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0710 | PR CTLSO A-P- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0810 | PR HALO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0820 | PR HALO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0830 | PR HALO CERV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0859 | PR MRI AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0861 | PR HALO REPL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0970 | PR TLSO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0972 | PR LSO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0974 | PR TLSO FULL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0976 | PR LSO FULL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0978 | PR AXILLARY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0980 | PR PERONEAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0982 | PR STOCKING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0984 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L0999 | PR ADD TO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1000 | PR CTLSO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1001 | PR CTLSO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1005 | PR TENSION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1010 | PR CTLSO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1020 | PR KYPHOSIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1025 | PR KYPHOSIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1030 | PR LUMBAR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1040 | PR LUMBAR OR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1050 | PR STERNAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1060 | PR THORACIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1070 | PR TRAPEZIUS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1080 | PR OUTRIGGER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1085 | PR OUTRIGGER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1090 | PR LUMBAR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1100 | PR RING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1110 | PR RING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1120 | PR COVERS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1200 | PR FURNSH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1210 | PR LATERAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1220 | PR ANTERIOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1230 | PR MILWAUKEE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1240 | PR LUMBAR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1250 | PR ANTERIOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1260 | PR ANTERIOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1270 | PR ABDOMINAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1280 | PR RIB GUSSET AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1290 | PR LATERAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1300 | PR BODY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1310 | PR POST- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1499 | PR SPINAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1600 | PR ABDUCT HIP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1610 | PR ABDUCT HIP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1620 | PR ABDUCT HIP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1630 | PR ABDUCT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1640 | PR PELV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1650 | PR HO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1652 | PR HO BI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1660 | PR HO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1680 | PR PELVIC & AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1681 | HIP ORTHOSIS, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK C, S, SK, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1685 | PR POST-OP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1686 | PR HO POST- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1690 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1700 | PR LEG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1710 | PR LEGG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1720 | PR LEGG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1730 | PR LEGG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1755 | PR LEGG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1810 | PR KO ELASTIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1812 | PR KO ELASTIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1820 | PR KO ELAS W/ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1830 | PR KO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1831 | PR KNEE ORTH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1832 | PR KO ADJ JNT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1834 | PR KO W/0 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1836 | PR RIGID KO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1840 | PR KO DEROT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1843 | PR KO SINGLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1844 | PR KO W/ADJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1845 | PR KO DOUBLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1846 | PR KO W ADJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1847 | PR KO DBL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1850 | PR KO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1851 | PR KO SINGLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1852 | PR KO DOUBLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1860 | PR KO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1900 | PR AFO SPRNG NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1901 | PR PREFAB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1902 | PR AFO ANKLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1904 | PR AFO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1906 | PR AFO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1907 | PR AFO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1910 | PR AFO SING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1920 | PR AFO SING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1930 | PR AFO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1932 | PR AFO RIG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1940 | PR AFO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1945 | PR AFO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1950 | PR AFO SPIRAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1951 | PR AFO SPIRAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1960 | PR AFO POS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1970 | PR AFO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1971 | PR AFO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1980 | PR AFO SING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L1990 | PR AFO DOUB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2000 | PR KAFO SING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2005 | PR KAFO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2010 | PR KAFO SNG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2020 | PR KAFO DBL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2030 | PR KAFO DBL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2034 | PR KAFO PLA AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2035 | PR KAFO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2036 | PR KAFO PLAS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2037 | PR KAFO PLAS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2038 | PR KAFO W/O AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2040 | PR HKAFO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2050 | PR HKAFO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2060 | PR HKAFO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2070 | PR HKAFO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2080 | PR HKAFO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2090 | PR HKAFO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2106 | PR AFO TIB FX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2108 | PR AFO TIB FX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2112 | PR AFO TIBIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2114 | PR AFO TIB FX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2116 | PR AFO TIBIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2126 | PR KAFO FEM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2128 | PR KAFO FEM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2132 | PR KAFO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2134 | PR KAFO FEM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2136 | PR KAFO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2180 | PR PLAS SHOE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2182 | PR DROP LOCK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2184 | PR LIMITED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2186 | PR ADJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2188 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2190 | PR WAIST BELT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2192 | PR PELVIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2200 | PR LIMITED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2210 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2220 | PR DORSI & AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2230 | PR SPLIT FLAT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2232 | PR ROCKER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2240 | PR ROUND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2250 | PR FOOT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2260 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2265 | PR LONG AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2270 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2275 | PR PLASTIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2280 | PR MOLDED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2300 | PR ABDUCTION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2310 | PR ABDUCTION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2320 | PR NON- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2330 | PR LACER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2335 | PR ANTERIOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2340 | PR PRE-TIBIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2350 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2360 | PR EXTENDED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2370 | PR PATTEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2375 | PR TORSION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2380 | PR TORSION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2385 | PR STRAIGHT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2387 | PR ADD LE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2390 | PR OFFSET AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2395 | PR OFFSET AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2397 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2405 | PR KNEE JOINT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2415 | PR KNEE JOINT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2425 | PR KNEE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2430 | PR KNEE JNT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2435 | DELETED 2716 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2492 | PR KNEE LIFT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2500 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2510 | PR TH/WGHT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2520 | PR TH/WGHT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2525 | PR TH/WGHT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2526 | PR TH/WGHT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2530 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2540 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2550 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2570 | PR HIP CLEVIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2580 | PR PELVIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2600 | PR HIP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2610 | PR HIP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2620 | PR PELVIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2622 | PR HIP JOINT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2624 | PR HIP ADJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2627 | PR PLASTIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2628 | PR METAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2630 | PR PELVIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2640 | PR PELVIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2650 | PR PELV & AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2660 | PR THORACIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2670 | PR THORAC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2680 | PR THORAC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2750 | PR PLATING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2755 | PR CARBON AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2760 | PR EXTENSION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2768 | PR ORTHO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2770 | PR LOW EXT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2780 | PR NON- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2785 | PR DROP LOCK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2795 | PR KNEE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2800 | PR KNEE CAP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2810 | PR KNEE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2820 | PR SOFT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2830 | PR SOFT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2840 | PR TIBIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2850 | PR FEMORAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2861 | PR TORSION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L2999 | PR LOWER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3000 | PR FT INSERT NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Flat Feet and CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3001 | PR FOOT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3002 | PR FOOT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3003 | PR FOOT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3010 | PR FOOT NO AUTHORIZATION REQUIRED MD GUIDELINE 1 (Flat Feet and CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3020 | PR FOOT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3030 | PR FOOT ARCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3031 | PR FOOT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3040 | PR FT ARCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3050 | PR FOOT ARCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3060 | PR FOOT ARCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3070 | PR ARCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3080 | PR ARCH SUPP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3090 | PR ARCH SUPP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3100 | PR HALLUS- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3140 | PR ABDUCTION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3150 | PR ABDUCT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3160 | PR SHOE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3161 | FOOT, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3170 | PR FOOT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3201 | PR OXFORD W NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3202 | PR OXFORD W/ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3203 | PR OXFORD W/ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3204 | PR HIGHTOP W/ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3206 | PR HIGHTOP W/ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3207 | PR HIGHTOP W/ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3208 | PR SURGICAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3209 | PR SURGICAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3211 | PR SURGICAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3212 | PR BENESCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3213 | PR BENESCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3214 | PR BENESCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3215 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3216 | PR ORTHOPED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3217 | PR LADIES NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3219 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3221 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3222 | PR MENS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3224 | PR WOMAN'S NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3225 | PR MAN'S NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3230 | PR CUSTOM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3250 | PR CUSTOM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3251 | PR SHOE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3252 | PR SHOE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3253 | PR SHOE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3254 | PR ORTH FOOT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3255 | PR ORTH FOOT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3257 | PR ORTH FOOT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3260 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3265 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3300 | PR SHO LIFT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3310 | PR SHOE LIFT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3320 | PR SHOE LIFT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3330 | PR LIFTS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3332 | PR SHOE LIFTS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3334 | PR SHOE LIFTS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3340 | PR SHOE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3360 | PR SHOE SOLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3370 | PR SHOE SOLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3380 | PR SHOE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3390 | PR SHOE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3400 | PR SHOE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3410 | PR SHOE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3420 | PR FULL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3430 | PR SHO HEEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3440 | PR HEEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3450 | PR SHOE HEEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3455 | PR SHOE HEEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3460 | PR SHOE HEEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3465 | PR SHOE HEEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3470 | PR SHOE HEEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3480 | PR SHOE HEEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3485 | PR SHOE HEEL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3500 | PR ORTHO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3510 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3520 | PR O SHOE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3530 | PR ORTHO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3540 | PR ORTHO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3550 | PR O SHOE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3560 | PR O SHOE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3570 | PR O SHOE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3580 | PR O SHOE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3590 | PR O SHOE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3595 | PR ORTHO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3600 | PR TRANS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3610 | PR TRANS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3620 | PR TRANS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3630 | PR TRANS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3640 | PR SHOE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3649 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3650 | PR SO 8 ABD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3651 | PR PREFAB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3652 | PR PREFAB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3660 | PR SO 8 AB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3670 | PR SO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3671 | PR SO CAP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3672 | PR SO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3673 | PR SO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3674 | PR SO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3675 | PR SO VEST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3677 | PR SO HARD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3702 | PR EO W/O NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3710 | PR ELBOW NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3720 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3730 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3740 | PR CUFFS ADJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3760 | PR EO ADJ JT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3761 | PR EO, ADJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3762 | PR RIGID EO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3763 | PR EWHO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3764 | PR EWHO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3765 | PR EWHFO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3766 | PR EWHFO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3806 | WHFO W/JOINT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3807 | PR WHFO,NO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3808 | PR WHFO, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3891 | PR TORSION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3900 | PR HINGE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3901 | PR HINGE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3904 | PR WHFO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3905 | PR WHO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3906 | PR WHO W/O NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3907 | PR WHFO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3908 | PR WRIST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3909 | PR PREFAB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3910 | PR WHFO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3911 | PR PREFAB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3912 | PR FLEX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3913 | PR HFO W/O NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3915 | PR WHO W AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3917 | PR PREFAB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3919 | PR HO W/O NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3921 | PR HFO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3922 | PR KNUCKLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3923 | PR HFO W/O NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3925 | FO PIP/DIP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3926 | PR THOMAS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3927 | FO PIP/DIP W/O NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3928 | PR FINGER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3929 | HFO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3931 | WHFO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3932 | PR SAFETY PIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3933 | PR FO W/O NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3934 | PR SAFETY PIN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3935 | PR FO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3956 | PR ADD JOINT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3960 | PR SEWHO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3961 | PR SEWHO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3962 | PR SEWHO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3963 | DELETED 2719 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3964 | PR SEO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3965 | PR ARM SUPP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3966 | PR MOBILE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3967 | PR SEWHO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3968 | PR FRICTION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3969 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3970 | PR ELEVAT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3971 | PR SEWHO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3972 | PR OFFSET/LAT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3973 | PR SEWHO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3974 | PR MOBILE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3975 | PR SEWHFO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3976 | PR SEWHFO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3977 | PR SEWHFO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3978 | PR SEWHFO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3980 | PR UPP EXT FX NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3981 | PR UE FX ORTH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3982 | PR UPPER EXT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3984 | PR UPPER EXT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3985 | PR FOREARM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3986 | PR HUMERAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3995 | PR SOCK NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L3999 | PR UPPER LIMB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4000 | PR REPL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4002 | PR REPLACE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4010 | PR REPLACE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4020 | PR REPLACE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4030 | PR REPLACE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4040 | PR REPLACE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4045 | PR REPLACE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4050 | PR REPLACE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4055 | PR REPLACE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4060 | PR REPLACE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4070 | PR REPLACE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4080 | PR REPL MET NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4090 | PR REPL MET NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4100 | PR REPL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4110 | PR REPL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4130 | PR REPLACE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4205 | PR ORTHO DVC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4210 | PR ORTH DEV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4350 | PR ANKLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4360 | PR PNEUMATI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4361 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4370 | PR PNEUMATIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4380 | PR PNEUMATIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4386 | PR NON- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4387 | PR NON- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4392 | PR REPLACE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4394 | PR REPLACE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4396 | PR STATIC AFO NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4398 | PR FOOT DROP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L4631 | PR AFO, WALK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5000 | PR SHO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5010 | PR MOLD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5020 | PR TIBIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5050 | PR ANK SYMES AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5060 | PR SYMES MET AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5100 | PR MOLDED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5105 | PR PLAST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5150 | PR MOLD SCKT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5160 | PR MOLD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5200 | PR KNE SING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5210 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5220 | PR NO KNEE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5230 | PR FEM FOCAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5250 | PR HIP CANAD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5270 | PR TILT TABLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5280 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5301 | PR BK MOLD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5311 | PR KNEE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5312 | PR KNEE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5321 | PR AK OPEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5331 | PR HIP DISART AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5341 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5400 | PR POSTOP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5410 | PR POSTOP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5420 | PR POSTOP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5430 | PR POSTOP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5450 | PR POSTOP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5460 | PR POSTOP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5500 | PR INIT BK PTB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5505 | PR INIT AK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5510 | PR PREP BK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5520 | PR PERP BK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5530 | PR PREP BK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5535 | PR PREP BK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5540 | PR PREP BK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5560 | PR PREP AK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5570 | PR PREP AK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5580 | PR PREP AK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5585 | PR PREP AK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5590 | PR PREP AK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5595 | PR HIP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5600 | PR HIP DISART AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5610 | PR ABOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5611 | PR AK 4 BAR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5613 | PR AK 4 BAR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5614 | PR 4-BAR LINK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5615 | ADDITION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5616 | PR AK UNIV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5617 | PR AK/BK SELF- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5618 | PR TEST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5620 | PR TEST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5622 | PR TEST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5624 | PR TEST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5626 | PR TEST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5628 | PR TEST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5629 | PR BELOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5630 | PR SYME TYP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5631 | PR AK/KNEE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5632 | PR SYMES AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5634 | PR SYMES AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5636 | PR SYMES AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5637 | PR BELOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5638 | PR BELOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5639 | PR BELOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5640 | PR KNEE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5642 | PR ABOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5643 | PR HIP FLEX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5644 | PR ABOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5645 | PR BK FLEX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5646 | PR BELOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5647 | PR BELOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5648 | PR ABOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5649 | PR ISCH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5650 | PR TOT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5651 | PR AK FLEX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5652 | PR SUCTION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5653 | PR KNEE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5654 | PR SOCKET AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5655 | PR SOCKET AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5656 | PR SOCKET AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5658 | PR SOCKET AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5661 | PR MULTI- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5665 | PR MULTI- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5666 | PR BELOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5668 | PR BK MOLDED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5670 | PR BK MOLDED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5671 | PR BK/AK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5672 | PR BK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5673 | PR SOCKET AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5676 | PR BK KNEE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5677 | PR BK KNEE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5678 | PR BK JOINT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5679 | PR SOCKET AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5680 | PR BK THIGH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5681 | PR INTL CUSTM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5682 | PR BK THIGH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5683 | PR INITIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5684 | PR BK FORK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5685 | PR BELOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5686 | PR BK BACK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5688 | PR BK WAIST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5690 | PR BK WAIST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5692 | PR AK PELVIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5694 | PR AK PELVIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5695 | PR AK SLEEVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5696 | PR AK/KNEE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5697 | PR AK/KNEE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5698 | PR AK/KNEE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5699 | PR SHOULDER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5700 | PR REPLACE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5701 | PR REPLACE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5702 | PR REPLACE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5703 | PR SYMES AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5704 | PR CUSTOM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5705 | PR CUSTOM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5706 | PR CUSTOM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5707 | PR CUSTOM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5710 | PR KNE-SHIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5711 | PR KNEE-SHIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5712 | PR KNEE-SHIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5714 | PR KNEE-SHIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5716 | PR KNEE-SHIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5718 | PR KNEE-SHIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5722 | PR KNEE-SHIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5724 | PR KNEE-SHIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5726 | PR KNEE-SHIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5728 | PR KNEE-SHIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5780 | PR KNEE-SHIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5785 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5790 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5795 | PR EXOSKEL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5810 | PR ENDOSKEL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5811 | PR ENDO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5812 | PR ENDO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5814 | PR ENDO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5816 | PR ENDO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5818 | PR ENDO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5822 | PR ENDO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5824 | PR ENDO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5826 | PR MINIATURE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5828 | PR ENDO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5830 | PR ENDO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5840 | PR MULTI- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5845 | PR KNEE-SHIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5848 | PR KNEE-SHIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5850 | PR ENDO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5855 | PR MECH HIP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5856 | PR ELEC KNEE- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5857 | PR ELEC KNEE- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5858 | PR STANCE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5910 | PR ENDO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5920 | PR ENDO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5925 | PR ABOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5930 | PR HIGH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5940 | PR ENDO BK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5950 | PR ENDO AK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5960 | PR ENDO HIP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5961 | PR ENDO POLY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5962 | PR BELOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5964 | PR ABOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5966 | PR HIP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5968 | PR MULTIAXIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5970 | PR FOOT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5971 | PR SACH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5972 | PR FLEXIBLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5973 | PR ANK-FOOT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5974 | PR FOOT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5975 | PR COMBO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5976 | PR ENERGY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5978 | PR FT PROSTH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5979 | PR MULTI- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5980 | PR FLEX FOOT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5981 | PR FLEX-WALK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5982 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5984 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5985 | PR LWR EXT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5986 | PR MULTI- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5987 | PR SHANK FT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5988 | PR VERTICAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5989 | DELETED 2728 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5990 | PR USER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5991 | ADDITION TO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK C, S, SK, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L5999 | PR LOWR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6000 | PR PAR HAND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6010 | PR HAND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6020 | PR PART HAND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6050 | PR WRST MLD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6055 | PR WRST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6100 | PR ELB MOLD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6110 | PR ELBOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6120 | PR ELBOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6130 | PR ELBOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6200 | PR ELBOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6205 | PR ELBOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6250 | PR ELBOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6300 | PR SHLDER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6310 | PR SHOULDER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6320 | PR SHOULDER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6350 | PR THORACIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6360 | PR THORACIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6370 | PR THORACIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6380 | PR POSTOP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6382 | PR POSTOP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6384 | PR POSTOP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6386 | PR POSTOP EA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6388 | PR POSTOP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6400 | PR BELOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6450 | PR ELB DISART AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6500 | PR ABOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6550 | PR SHLDR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6570 | PR SCAP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6580 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6582 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6584 | PR ELBOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6586 | PR ELBOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6588 | PR SHDR FAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6590 | PR SHDR FAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6600 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6605 | PR SINGLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6610 | PR FLEXIBLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6611 | PR ADDITIONAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6615 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6616 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6620 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6621 | PR FLEX/EXT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6623 | PR SPRING- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6624 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6625 | PR ROTATION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6628 | PR QUICK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6629 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6630 | PR STAINLESS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6632 | PR LATEX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6635 | PR LIFT ASSIST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6637 | PR NUDGE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6638 | PR ELEC LOCK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6640 | PR SHOULDER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6641 | PR EXCURSION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6642 | PR EXCURSION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6645 | PR SHOULDER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6646 | PR MULTIPO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6647 | PR SHOULDER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6648 | PR EXT PWRD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6650 | PR SHOULDER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6655 | PR STANDARD AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6660 | PR HEAVY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6665 | PR TEFLON OR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6670 | PR HOOK TO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6672 | PR HARNESS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6675 | PR HARNESS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6676 | PR HARNESS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6677 | PR UE TRIPLE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6680 | PR TEST SOCK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6682 | PR TEST SOCK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6684 | PR TEST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6686 | PR SUCTION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6687 | PR FRAME TYP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6688 | PR FRAME TYP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6689 | PR FRAME TYP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6690 | PR FRAME TYP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6691 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6692 | PR SILICONE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6693 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6694 | PR ELBOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6695 | PR ELBOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6696 | PR CUS ELBO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6697 | PR CUS ELBO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6698 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6703 | PR TERM DEV, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6704 | PR TERM DEV, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6705 | PR TERMINAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6706 | PR TERM DEV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6707 | PR TERM DEV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6708 | PR TERM DEV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6709 | PR TERM DEV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6711 | PR PED TERM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6712 | PR PED TERM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6713 | PR PED TERM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6714 | PR PED TERM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6715 | PR TERM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6720 | PR TERMINAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6721 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6722 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6805 | PR TERM DEV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6806 | PR TRS GRIP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6807 | PR TERM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6808 | PR TERM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6809 | PR TRS SUPER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6810 | PR TERM DEV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6880 | PR ELEC HAND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6881 | PR TERM DEV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6882 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6883 | PR REPLC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6884 | PR REPLC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6885 | PR REPLC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6890 | PR PREFAB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6895 | PR CUSTOM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6900 | PR HAND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6905 | PR HAND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6910 | PR HAND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6915 | PR HAND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6920 | PR WRIST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6925 | PR WRIST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6930 | PR BELOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6935 | PR BELOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6940 | PR ELBOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6945 | PR ELBOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6950 | PR ABOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6955 | PR ABOVE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6960 | PR SHLDR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6965 | PR SHLDR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6970 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L6975 | PR INTERSCAP- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7007 | PR ADULT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7008 | PR PEDIATRIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7009 | PR ADULT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7010 | PR HAND OTTO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7015 | PR HAND SYS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7020 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7025 | PR ELECTRON AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7030 | PR HAND SYS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7035 | PR ELECTRON AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7040 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7045 | PR PEDIATRIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7170 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7180 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7181 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7185 | PR ELECTRON AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7186 | PR ELECTRON AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7190 | PR ELBOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7191 | PR ELBOW AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7360 | SIX VOLT BAT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7362 | BATTERY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7364 | TWELVE VOLT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7366 | BATTERY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7367 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7368 | PR LITHIUM ION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7400 | PR ADD UE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7401 | PR ADD UE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7402 | PR ADD UE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7403 | PR ADD UE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7404 | PR ADD UE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7405 | PR ADD UE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7499 | PR UPPER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7510 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7520 | PR REPAIR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7600 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L7700 | PR PROS SOC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8000 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8001 | PR BREAST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8002 | PR BRST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8010 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8015 | PR EXT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8020 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8030 | PR BREAST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8031 | PR BREAST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8032 | PR REUSABLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8035 | PR CUSTOM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8039 | PR BREAST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8040 | PR NASAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8041 | PR MIDFACIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8042 | PR ORBITAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8043 | PR UPPER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8044 | PR HEMI- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8045 | PR AURICULAR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8046 | PR PARTIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8047 | PR NASAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8300 | PR TRUSS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8310 | PR TRUSS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8320 | PR TRUSS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8330 | PR TRUSS ADD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8400 | PR SHEATH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8410 | PR SHEATH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8415 | PR SHEATH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8417 | PR PROS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8420 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8430 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8435 | PR PROS SOCK NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8440 | PR SHRINKER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8460 | PR SHRINKER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8465 | PR SHRINKER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8470 | PR PROS SOCK NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8480 | PR PROS SOCK NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8485 | PR PROS SOCK NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8499 | PR UNLISTED AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8500 | PR ARTIFICIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8501 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8507 | PR TRACH- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8509 | PR TRACH- NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8510 | PR VOICE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8600 | PR IMPLANT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8603 | PR COLLAGEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8604 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8606 | PR SYNTHETIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8610 | PR OCULAR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8614 | PR COCHLEAR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8615 | PR COCH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8616 | PR COCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8617 | PR COCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8618 | PR COCH NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8619 | PR REPLACE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8621 | PR REPL ZINC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8622 | PR REPL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8623 | PR LITH ION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8624 | PR LITH ION NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8625 | PR CHARGER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8627 | PR CID EXT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8628 | PR CID EXT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8629 | PR CID NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8680 | PR IMPLT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8681 | PR PT PRGRM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8682 | PR IMPLT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8683 | PR RADIOFQ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8684 | PR RADIOF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8685 | PR IMPLT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8686 | PR IMPLT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8687 | PR IMPLT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8688 | PR IMPLT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8689 | PR EXTERNAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8690 | PR AUD OSSEO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8691 | PR AOI SND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8692 | PR NON- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8693 | PR AUD OSSEO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8694 | PR AOI AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| L8695 | PR EXTERNAL NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| M0201 | PR ADMIN OF NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 6/8/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| M0220 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| M0221 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| M0222 | INTRAVENOUS NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| M0223 | BEBTELOVIMAB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| M0239 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 4/30/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| M0240 | PR CASIRI AND NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| M0241 | PR CASIRI AND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| M0243 | PR CASIRIVI NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| M0244 | PR CASIRIVI AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| M0245 | PR BAMLAN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| M0246 | PR BAMLAN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, 2/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| M0247 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| M0248 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| P9025 | PR PLASMA NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| P9026 | PR CRYO FIB NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0138 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 7/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0163 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0167 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0169 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0175 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0220 | PR EVUSHELD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0221 | TIXAGEV AND NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK, 6/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0222 | BEBTELOVIMAB AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0239 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 4/30/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0243 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0244 | PR CASIRIVI AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0245 | PR NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0247 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, 1/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0477 | PR PWR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0480 | PR DRIVER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0481 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0482 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0483 | PR MONITOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0484 | PR MONITOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0485 | PR MONITOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0486 | PR MON CABLE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0487 | PR LEADS ANY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0488 | PR PWR PACK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0489 | PR PWR PCK AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0490 | PR EMR PWR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0491 | PR EMR PWR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0492 | PR EMR PWR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0493 | PR EMR PWR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0494 | PR EMR HD NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0495 | PR CHARGER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0496 | PR BATTERY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0497 | PR BAT CLPS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0498 | PR HOLSTER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0499 | PR BELT/VEST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0500 | PR FILTERS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0501 | PR SHWR COV AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0502 | PR MOBILITY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0503 | PR BATTERY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0504 | PR PWR ADPT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0505 | PR MISCL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0506 | PR LITH-ION AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0507 | PR MISC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q0508 | PR MISC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q2017 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q2026 | PR RADIESSE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q2028 | PR INJ, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q2040 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q2041 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q2042 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q2043 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q2053 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q2054 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q2055 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q2056 | CILTACABTAGE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q3014 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4101 | PR APLIGRAF AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4102 | PR OASIS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4106 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4110 | PR PRIMATRIX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4111 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4114 | PR INTEGRA AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4115 | PR ALLOSKIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4121 | PR THERASKIN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4132 | PR GRAFIX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4133 | PR GRAFIX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4137 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4145 | PR EPIFIX, INJ, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4151 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4154 | PR BIOVANCE 1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4159 | PR AFFINITY1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4160 | PR NUSHIELD 1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4163 | PR WOUNDEX AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4173 | PR PALINGEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4174 | PR PALINGEN AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4186 | PR EPIFIX 1 SQ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4187 | PR EPICORD 1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4195 | PR PURAPLY 1 AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4196 | PR PURAPLY AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4272 | ESANO A, PER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4273 | ESANO AAA, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4274 | ESANO AC, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4275 | ESANO AC, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4276 | ORION, PER AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4277 | WOUNDPLUS AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4278 | EPIEFFECT, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4280 | XCELL AMNIO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4281 | BARRERA SL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4282 | CYGNUS DUAL, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4283 | BIOVANCE TRI- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4284 | DERMABIND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4285 | NUDYN DL OR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q4286 | NUDYN SL OR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION S, SK, C, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5101 | PR INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5103 | PR INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5104 | PR INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5105 | PR INJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 4/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5107 | PR INJ MVASI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5108 | PR INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5110 | PR NIVESTYM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5111 | PR INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5112 | PR INJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5113 | PR INJ NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5114 | PR INJ OGIVRI NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5116 | PR INJ., NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5117 | PR INJ., NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5118 | PR INJ., NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5119 | PR INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5120 | PR INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5121 | PR INJ. AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5122 | PR INJ, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5123 | PR INJ. RIABNI, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5124 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5125 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5126 | PR INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5127 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5128 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5129 | INJECTION, NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5130 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q5131 | INJECTION, AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q9991 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| Q9992 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| R0070 | W/US GDN 1ST PROVIDERS ( - ), NECESSITY | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| R0075 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| R0076 | W/US GDN 1ST PROVIDERS ( - ), NECESSITY | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S0013 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S0028 | PR INJECTION, NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S0201 | PR PARTIAL NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S0255 | PR HOSPICE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S0265 | PR GENETIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S0271 | HOME AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S0515 | PR SCLERAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S0620 | PR ROUTINE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S0621 | PR ROUTINE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S1015 | PR IV TUBING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S1040 | PR CRANIAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S1091 | PR STENT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 7/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S2066 | BREAST GAP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S2067 | BREAST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S2068 | BREAST DIEP NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 6/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S2202 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 10/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S5101 | PR ADULT DAY AUTHORIZATION REQUIRED USE OF DAHS IS IDENTIFIED CLINICAL INFORMATION SK S, C, CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S5151 | PR UNSKILLED AUTHORIZATION REQUIRED USE OF LTSS IS IDENTIFIED CLINICAL INFORMATION SK S, C, CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S5161 | PR EMER AUTHORIZATION REQUIRED USE OF PCS AND CFC IS CLINICAL INFORMATION SK S, C, CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S5165 | PR HOME AUTHORIZATION REQUIRED USE OF LTSS IS IDENTIFIED CLINICAL INFORMATION SK S, C, CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S8101 | PR SPACER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S8185 | PR FLUTTER NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S8189 | PR TRACH AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S8265 | PR HABERMAN NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S8270 | PR ENURESIS NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S8301 | PR INFECT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK,CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S8415 | PR SUPPLIES NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S8420 | PR CUSTOM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S8421 | PR READY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S8422 | PR CUSTOM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S8423 | PR CUSTOM NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S8424 | PR READY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S8425 | PR CUSTOM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S8426 | PR CUSTOM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S8427 | PR READY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S8428 | PR READY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S8429 | PR GRADIENT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S8450 | PR SPLINT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S8451 | PR SPLINT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S8452 | PR SPLINT NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S8999 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 2/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S9110 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 3/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S9123 | PR NURSING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S9124 | PR NURSING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S9126 | PR HOSPICE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S9140 | PR DIABETIC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S9152 | SPEECH NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 8/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S9208 | PR HOME AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S9209 | PR HOME AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S9211 | PR HOME AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S9212 | PR HM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S9213 | PR HM AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S9214 | PR HM GEST AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S9351 | PR HIT CONT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S9379 | PR HIT NOC AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S9435 | PR MEDICAL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK,CP 6/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S9445 | PR PT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S9470 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S9480 | PR INTENSIVE NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S9482 | PR FAMILY AUTHORIZATION REQUIRED USE OF LTSS IS IDENTIFIED CLINICAL INFORMATION SK S, C, CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| S9560 | PR HT INJ AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T1000 | PR PRIVATE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION SK, S, C CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T1005 | PR RESPITE AUTHORIZATION REQUIRED USE OF LTSS IS IDENTIFIED CLINICAL INFORMATION SK S, C, CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T1007 | PR TREATMENT NO AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T1015 | PR CLINIC NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, 5/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T1017 | PR TARGETED NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T1019 | PR PERSONAL AUTHORIZATION REQUIRED USE OF PCS AND CFC IS CLINICAL INFORMATION SK, STAR C, CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T1025 | PR PED COMPR AUTHORIZATION REQUIRED USE OF PPECC IS IDENTIFIED CLINICAL INFORMATION SK S, C, CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T1026 | PR PED COMPR AUTHORIZATION REQUIRED USE OF PPECC IS IDENTIFIED CLINICAL INFORMATION SK S, C, CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T1999 | PR NOC RETAIL AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 11/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T2002 | PR N-ET; PER AUTHORIZATION REQUIRED USE OF PPECC IS IDENTIFIED CLINICAL INFORMATION SK S, C, CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T2027 | PR SPEC AUTHORIZATION REQUIRED USE OF LTSS IS IDENTIFIED CLINICAL INFORMATION SK S, C, CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T2028 | PR SPECIAL AUTHORIZATION REQUIRED USE OF LTSS IS IDENTIFIED CLINICAL INFORMATION SK S, C, CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T2029 | PR SPECIAL AUTHORIZATION REQUIRED USE OF LTSS IS IDENTIFIED CLINICAL INFORMATION SK S, C, CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T2038 | PR COMM AUTHORIZATION REQUIRED USE OF LTSS IS IDENTIFIED CLINICAL INFORMATION SK S, C, CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T2039 | PR VEHICLE AUTHORIZATION REQUIRED USE OF LTSS IS IDENTIFIED CLINICAL INFORMATION SK S,C, CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T2040 | PR FINANCIAL AUTHORIZATION REQUIRED USE OF PCS AND CFC IS CLINICAL INFORMATION SK S, C, CP 12/1/2022 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T2042 | PR HOSPICE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T2043 | PR HOSPICE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T2044 | PR HOSPICE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T2045 | PR HOSPICE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T2046 | PR HOSPICE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T2101 | PR BREAST NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 12/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T4521 | PR ADULT SIZE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T4522 | PR ADULT SIZE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T4523 | PR ADULT SIZE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T4524 | PR ADULT SIZE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T4525 | PR ADULT ZISE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T4526 | PR ADULT ZIDE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T4527 | PR ADULT ZIDE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T4528 | PR ADULT ZIDE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T4529 | PR PED SIZE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T4530 | PR PED SIZE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T4531 | PR PED SIZE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T4532 | PR PED SIZE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T4533 | PR YOUTH SIZE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T4534 | PR YOUTH SIZE AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T4535 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T4543 | PR DISP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| T4544 | PR ADLT DISP AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| U0001 | PR 2019-NCOV NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 5/12/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| U0002 | PR COVID-19 NO AUTHORIZATION REQUIRED CLINICAL INFORMATION S, SK, C, 5/12/2023 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2020 | PR VISION AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2025 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2100 | PR LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2101 | PR SINGLE AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2102 | PR SINGL VISN AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2103 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2104 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2105 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2106 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2107 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2108 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2109 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2110 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2111 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2112 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2113 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2114 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2199 | PR LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2200 | PR LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2201 | PR LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2202 | PR LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2203 | PR LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2204 | PR LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2205 | PR LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2206 | PR LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2207 | PR LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2208 | PR LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2209 | PR LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2211 | PR LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2212 | PR LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2213 | PR LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2214 | PR LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2300 | PR LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2303 | PR LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2304 | PR LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2307 | PR LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2500 | PR CONTACT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2510 | PR CNTCT GAS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2511 | PR CNTCT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2520 | PR CONTACT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2521 | PR CNTCT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2523 | PR CNTCT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2526 | CONTACT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK, CP 1/1/2024 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2531 | PR CONTACT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2599 | PR CONTACT AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2623 | PR PLASTIC AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2624 | PR POLISHING AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2625 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2627 | PR SCLERAL AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2628 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2784 | PR LENS AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V2799 | PR AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 11/1/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5010 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5011 | PR HEARING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5014 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5020 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5030 | PR BODY- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5040 | PR BODY- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5050 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5060 | PR BEHIND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5070 | PR GLASSES AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5080 | PR GLASSES AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5090 | PR HEARING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5095 | PR IMPLANT AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5100 | PR BODY- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5110 | PR HEARING NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5120 | PR BODY- AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5130 | PR IN EAR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5140 | PR BEHIND AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5150 | PR GLASSES AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5160 | PR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5171 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5172 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5181 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5190 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5200 | PR DISP FEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5211 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5212 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5213 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5214 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5215 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5221 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5230 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5240 | PR DISP FEE NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5241 | PR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5242 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5243 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5244 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5245 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5246 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5247 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5248 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5249 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5250 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5251 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5252 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5253 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5254 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5256 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5257 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5258 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5259 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5260 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5261 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5264 | PR EAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5265 | PR EAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5266 | PR BATTERY NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5267 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5273 | PR ALD FOR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5275 | PR EAR NO AUTHORIZATION REQUIRED CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5298 | PR HEARING AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |
| V5336 | PR REPAIR AUTHORIZATION REQUIRED TMPPM CLINICAL INFORMATION C, S, SK CP 5/10/2021 | 2026-07-06 | 2023-06-01 | 97% | [PDF] Prior Authorization Requirements - Driscoll Health Plan |