SHBP Precertification List Form

CarelonRx, Inc. is an independent company providing pharmacy benefit management services on behalf of the health plan. Carelon Medical Benefits Management, Inc. is a separate company providing utilization review services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. GA-BCBS-CM-004080-26-S1382 | March 2026 State Health Benefit Plan precertification list as of

January 1, 2026

Georgia | Anthem Blue Cross and Blue Shield | Commercial

To obtain precertification (prior authorization):

 To obtain precertification (prior authorization) for the State Health Benefit Plan (SHBP), both in-network and out -of-network care providers must call the Anthem Utilization Management Team at 855 -668 -6442 .  Care providers can use Interactive Care Reviewer (ICR) or Availity Essentials, our self-service care provider applications, to request inpatient and outpatient precertification, as well as to inquire about or find information on a precertification previous ly submitted via phone, fax, ICR, etc. Access ICR by visiting https://Availity.com.

• Note that ICR is not currently available for BlueCard ®; requests involving behavioral health (BH) or transplant services; or services administered by Carelon Medical Benefits Management, Inc.

  Eligibility and benefits:

   Eligibility and benefits can be verified by accessing https://Availity.com or by calling the number on the back of the member’s identification card. Service precertification is based on member’s benefit plan and eligibility at the time the service is reviewed and approved. The care provider is responsible for verification of memb er eligibility and covered benefits.

   It is your responsibility to notify Anthem of certain services and obtain precertification. Except in the case of an emergency, failure to obtain precertification before rendering the designated services listed below will not be eligible for reimbursement. To avoid issues with reimbursement of serv ices for hospital and medical benefits, call before the service is rendered or no later than two business days after an emergency admission or as soon as reasonably possible.

   If procedures are not prior approved, they will not be eligible for reimbursement due to a lack of precertification. Any services or days determined to be not medically necessary will not be covered. For in -network care providers, there are no late notice penalties. For out-of-network care providers, there is a late notice penalty of 50% of the maximum allowed amounts for covered services. If you are unsure whether a service is covered and

State Health Benefit Plan precertification list as of January 1, 2026

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requires precertification, call 855 -668 -6442 . Precertification does not guarantee eligibility or payment.

Services that require precertification:

 Inpatient services :

• Acute inpatient (including transplants)

• Emergency admissions (requires notification no later than two business days after admission)
• Inpatient rehabilitation

• Maternity delivery if inpatient stay extends 48 hours for nausea, vomiting, diarrhea (NVD), and 96 hours following caesarean delivery

• Out-of-network or out -of-area non -emergency services

• Sub -acute inpatient (skilled nursing and long -term care)
   Carelon Medical Benefits Management :

• Diagnostic imaging management services are provided by Carelon Medical Benefits Management for health plan members. Carelon Medical Benefits Management is a nationally recognized leader in specialty benefits management. To submit a request for any of the s ervices below, visit the provider website at providerportal.com . From the drop-down menu, select Anthem. You may also call Carelon Medical Benefits Management at 866 -714 -1103 , Monday – Friday, 8 a.m. to 6 p.m. ET.

  ▪ Cardiac — Diagnostic Services (Echocardiography or Nuclear Cardiology)

  ▪ Musculoskeletal (MSK) : ▫ Ankle replacement
  ▫ Hip replacement
  ▫ Implanted (epidural and subcutaneous) spinal cord stimulators (SCS)

  ▫ Knee replacement
  ▫ Meniscal allograft transplantation of the knee

  ▫ Sacroiliac joint fusion (minimally invasive)

  ▫ Shoulder replacement

  ▫ Spine surgery
  ▫ Treatment of osteochondral defects of the knee and ankle

  ▫ Vertebroplasty or kyphoplasty

  ▪ Radiation therapy
  ▪ Radiology – diagnostic services (CT scan, computed tomographic angiography [CTA], magnetic resonance angiography [MRA], MRI, Myocardial Strain Imaging, PET scan)

  ▪ Sleep testing and therapy services

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 Behavioral health services :

• Call 855 -679 -5725 for behavioral health precertification

  ▪ Acute inpatient admissions

  ▪ Applied behavioral analysis (ABA) therapy

  ▪ Behavioral health Intensive in -home programs
  ▪ Inpatient mental health/substance abuse (in -network or out -of-network) within 24 hours of admission.

  ▪ Intensive outpatient therapy (IOP)

  ▪ Partial hospitalization (PHP)

  ▪ Residential treatment center (RTC)

  ▪ Transcranial magnetic stimulation (TMS)

   Diagnostic testing :

• Breast cancer (BRCA) genetic testing

• Chromosomal microarray analysis (CMA) for developmental delay, autism spectrum disorder, intellectual disability, and congenital anomalies

• Gene expression profiling for managing breast cancer treatment

• Gene mutation testing for cancer susceptibility and management

• Genetic testing for heritable cardiac conditions

• Per- and polyfluoroalkyl substances (PFAS) testing

• Preimplantation genetic diagnosis testing

• Prostate saturation biopsy

• Testing for biochemical markers for Alzheimer's disease

• Whole genome sequencing, whole exome sequencing, gene panels, and molecular profiling
• Wireless capsule for the evaluation of suspected gastric and intestinal motility disorders
   Durable Medical Equipment (DME) and prosthetics :

• Augmentative and alternative communication (AAC) devices with digitized or synthesized speech output

• Brain computer interface rehabilitation devices

• Compression devices for lymphedema

• External upper limb stimulation for the treatment of tremors

• Functional electrical stimulation (FES); threshold electrical stimulation (TES)

• Home video -assisted robotic rehabilitation systems

• Implantable infusion pumps

• Implantable peripheral nerve stimulation devices as a treatment for pain

• Implanted artificial iris devices

• Intrapulmonary percussive ventilation device

• Lower limb prosthesis and microprocessor controlled lower limb prosthesis

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• Microprocessor controlled knee -ankle -foot orthosis

• Myoelectric upper extremity prosthetic devices

• Neuromuscular electrical training for the treatment of obstructive sleep apnea or snoring

• Noninvasive electrical bone growth stimulation of the appendicular skeleton

• Powered robotic lower body exoskeleton devices

• Robotic arm assistive devices

• Standing frames

• Ultrasonic diathermy devices

• Wheeled mobility devices: wheelchairs — powered, motorized, with or without power seating systems and power -operated - vehicles (POVs)

   Enzyme replacement :

• Revcovi (elapegademase -lvlr)  Immunotherapy :

• Tecelra (afamitresgene autoleucel)

   Outpatient or other inpatient services :

• Ablative techniques as a treatment for Barrett’s esophagus

• Aduhelm (aducanumab)

• Ambulance services: air and water

• Ambulance services: ground; non -emergent

• Axial lumbar interbody fusion

• Balloon sinus ostial dilation

• Bariatric surgery and other treatments for clinically severe obesity

• Bioengineered and composite products for wound healing and soft tissue grafting

• Blepharoplasty, blepharoptosis repair, and brow lift

• Bone -anchored and bone conduction hearing aids

• Breast procedures, including reconstructive surgery, implants, and other breast procedures
• Bronchial thermoplasty

• Cardiac contractility modulation therapy

• Cardiac resynchronization therapy with or without an implantable cardioverter
  defibrillator for the treatment of heart failure

• Carotid vertebral and intracranial artery angioplasty with or without stent placement

• Catheter -based embolization procedures for malignant lesions outside the liver

• Cellular Therapy Products for Allogeneic Stem Cell Transplantation

• Cervical and thoracic discography

• Clinical trials

• Cochlear implants and auditory brainstem implants

• Corneal collagen cross -linking

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• Cosmetic and reconstructive services: head and neck, including but not limited to:

  ▪ Cranial nerve procedures

  ▪ Facial plastic surgery

  ▪ Neck tuck (submental lipectomy)

  ▪ Otoplasty
  ▪ Rhinophyma
  ▪ Rhinoplasty
  ▪ Rhytidectomy (face lift)

• Cosmetic and reconstructive services: skin related, including but not limited to:

  ▪ Chemical peels

  ▪ Collagen injections

  ▪ Cutaneous hemangioma, port wine stain, and other vascular lesions

  ▪ Hair procedures
  ▪ Injection of dermal fillers

  ▪ Laser and surgical treatment of rosacea and telangiectasia

  ▪ Other cosmetic skin procedures

  ▪ Treatment of keloids and scar revision

• Cosmetic and reconstructive services: trunk and groin, including but not limited to:

  ▪ Brachioplasty
  ▪ Buttock or thigh lift
  ▪ Congenital abnormalities

  ▪ Lipectomy or liposuction
  ▪ Pectus excavatum or carinatum

  ▪ Procedures on the genitalia

• Cryosurgical, radiofrequency or laser ablation to treat solid tumors outside the liver

• Deep brain, cortical, and cerebellar stimulation

• Dental care due to accident or injury

• Diaphragmatic or phrenic nerve stimulation and diaphragm pacing systems

• Doppler -guided transanal hemorrhoidal dearterialization

• Electric tumor treatment field (TTF)

• Electrophysiology -Guided Noninvasive Stereotactic Cardiac Radio Ablation

• Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities

• Extracorporeal shock wave therapy

• Extraosseous subtalar joint implantation and subtalar arthroereisis

• Focal laser ablation for the treatment of prostate cancer

• Functional endoscopic sinus surgery (FESS)

• Gender affirming surgery

• Hepzato Kit ™ (melphalan hepatic delivery system)

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• Histotripsy
• Home parenteral nutrition

• Hyperbaric oxygen therapy (systemic or topical)

• Immunoprophylaxis for respiratory syncytial virus (RSV) or Synagis (palivizumab)

• Implantable ambulatory event monitors and mobile cardiac telemetry

• Implantable shock absorber for treatment of knee osteoarthritis

• Implanted devices for spinal stenosis

• Implanted port delivery systems to treat ocular disease

• Intracardiac ischemia monitoring

• Intraocular anterior segment aqueous drainage devices (without extraocular reservoir)

• Keratoprosthesis

• Leadless pacemaker

• Locoregional and surgical techniques for treating primary and metastatic liver malignancies

• Lower esophageal sphincter augmentation devices for the treatment of gastroesophageal reflux disease (GERD)

• Lysis of epidural adhesions

• Mandibular or maxillary (orthognathic) surgery

• Manipulation under anesthesia

• Mechanical circulatory assist devices (ventricular assist devices, percutaneous ventricular assist devices, and artificial hearts)

• Microsurgical procedures for the prevention or treatment of lymphedema

• Minimally invasive treatment of the posterior nasal nerve to treat rhinitis

• MRI -guided high -intensity focused ultrasound ablation for non -oncologic indications

• Nasal surgery for the treatment of obstructive sleep apnea and snoring

• Open sacroiliac joint fusion

• Oral, pharyngeal, and maxillofacial surgical treatment for obstructive sleep apnea or snoring
• Outpatient cardiac hemodynamic monitoring using a wireless sensor for heart failure management

• Panniculectomy and abdominoplasty (including diastasis recti repair)

• Parenteral antibiotics for the treatment of Lyme disease

• Patent foramen ovale and left atrial appendage for stroke prevention

• Percutaneous and endoscopic spinal surgery

• Percutaneous vertebral disc and vertebral endplate procedures

• Perirectal spacers for use during prostate radiotherapy

• Penile prosthesis implantation

• Presbyopia and astigmatism -correcting intraocular lenses

• Products for wound healing and soft tissue grafting: medically necessary uses

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• Reduction mammaplasty

• Sacral nerve stimulation and percutaneous tibial nerve stimulation for urinary and fecal incontinence; urinary retention
• Sacral nerve stimulation as treatment of neurogenic bladder secondary to spinal cord injury

• Self -expanding absorptive sinus ostial dilation

• Sipuleucel -T (Provenge®) autologous cellular immunotherapy for the treatment of prostate cancer

• Specialty medications or injectable medications

• Surgical and ablative treatments for chronic headaches

• Temporomandibular disorders

• Therapeutic apheresis

• Transcatheter ablation of arrhythmogenic foci in the pulmonary veins

• Transcatheter heart valve procedures

• Transendoscopic therapy for GERD, dysphagia, and gastroparesis

• Transmyocardial or periventricular device closure of ventricular septal defects

• Treatments for urinary incontinence

• Treatment of varicose veins (lower extremities)

• Vagus nerve stimulation

• Vein embolization as a treatment for pelvic congestion syndrome and varicocele

• Venous angioplasty with or without stent placement or venous stenting alone

• Viscocanalostomy and canaloplasty

• Wireless cardiac resynchronization therapy for left ventricular pacing

• Xofigo (Radium Ra 223 dichloride)

   Transplant :

• Acute inpatient (including transplants)

• Inpatient admits for ALL solid organ and bone marrow, and stem cell transplants (including kidney only transplants)

• Outpatient: all procedures considered to be transplant or transplant related including but not limited to:
  ▪ Chimeric antigen receptor (CAR) T -cell immunotherapy treatment including but not limited to: ▫ Axicabtagene ciloleucel (Yescarta ™) ▫ Tisagenlecleucel (Kymriah ™) ▫ Brexucabtagene Autoleucel (Tecartus)

  ▫ Lisocabtagene maraleucel (Breyanzi)

  ▫ Idecabtagene vicleucel (Abecma)

• Donor leukocyte infusion
• Hematopoietic stem cell transplantation for diabetes mellitus

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• Intrathecal treatment of spinal muscular atrophy (SMA)

• Stem cell or bone marrow transplant (with or without myeloablative therapy)

• Thymus tissue transplantation

• Gene therapy treatment and replacement including but not limited to:

  ▪ Autologous cell sheet -based gene therapy for treatment of dystrophic epidermolysis bullosa

  ▪ Gene therapy for allogeneic bone marrow -derived mesenchymal stromal cell therapy ▪ Gene therapy for aromatic l -amino acid decarboxylase deficiency (Kebilidi ™) ▪ Gene therapy for the treatment of adult patients with high -risk, Bacillus Calmette -Guérin (BCG) -unresponsive non -muscle invasive bladder cancer Adstiladrin (nadofaragene firadenovec -vncg)
  ▪ Gene therapy for the treatment of duchenne muscular dystrophy (DMD) Amondys 45 (casimersen)

  ▪ Gene encapsulated cell therapy for degenerative ocular disease

  ▪ Gene therapy for hemophilia (Roctavian ™) ▪ Gene therapy for ocular conditions or voretigene neparvovec -rzyl (Luxturna ™) ▪ Gene therapy for spinal muscular atrophy or onasemnogene abeparvovec -xioi (Zolgensma ®)

   Specialty Medications :

• Specialty medications will be reviewed by CarelonRx, Inc. Precertification (prior authorization) requirement does not indicate coverage. Check benefits to see if the specialty medication is covered under Anthem medical or CVS Caremark ® pharmacy. If you have questions regarding the specialty medications covered under Anthem medical that require precertification, call 855 -668 -6442 .

  Disclaimer: Services listed require precertification and will be denied if rendered without the appropriate precertification, regardless of whether rendered in or out -of-network.