| |
Medication Preauthorization
|
| | HCM.MED.003: Erectile Dysfunction Medication |
| | HCM.MED.003.010: Alprostadil |
| | HCM.MED.003.020: Caverject/Muse |
| | HCM.MED.003.030: Levitra |
| | HCM.MED.003.040: Sildenafil |
| | HCM.MED.003.050: Uprima |
| | HCM.MED.003.060: Vardenafil |
| | HCM.MED.003.070: Viagra |
| | HCM.MED.004: Sonata Limitations |
| | HCM.MED.016: Cox-2 Inhibitor Medications |
| | HCM.MED.016.020: Celebrex |
| | HCM.MED.016.030: Celecoxib |
| | HCM.MED.037: Meridia |
| | HCM.MED.037.010: Xenical |
| | HCM.MED.050: Sporanox |
| | HCM.MED.050.010: Itraconazole |
| | HCM.MED.051: Lamisil |
| | HCM.MED.051.010: Terbinafine |
| | HCM.MED.051.020: Ciciopirox |
| | HCM.MED.051.030: Penlac |
| | HCM.MED.052: Lotronex |
| | HCM.MED.052.010: Alosteron |
| | HCM.MED.053: Provigil |
| | HCM.MED.053.010: Modafinil |
| | HCM.MED.079: Generic Drug Substitution |
| | HCM.MED.080: Therapeutic Interchange |
| | HCM.MED.104: Hormone Therapy Medications |
| | HCM.MED.111: Prior Authorization Criteria for Managed Drug Limitations |
| | HCM.MED.114: Botox |
| | HCM.MED.114.010: Botulinum Toxin |
| | HCM.MED.130: Flumadine |
| | HCM.MED.130.010: Rimantadine Hydrochloride |
| | HCM.MED.131: Relenza |
| | HCM.MED.131.010: Zanamivir |
| | HCM.MED.132: Tamiflu |
| | HCM.MED.132.010: Oseltamivir |
| | HCM.MED.137: Medication Authorizations |
| | HCM.MED.141: Prenatal Vitamins/Iron/B12 |
| | HCM.MED.143: Proton Pump Inhibitor Meds |
| | HCM.MED.143.010: Aciphex |
| | HCM.MED.143.020: Esomeprazole |
| | HCM.MED.143.030: Iansoprazole |
| | HCM.MED.143.040: Nexium |
| | HCM.MED.143.050: Pantoprazole |
| | HCM.MED.143.060: Prevacid |
| | HCM.MED.143.070: Protonix |
| | HCM.MED.143.080: Rabeprazole |
| | HCM.MED.167: Fluoride Supplementation and Treatments |
| | HCM.MED.179: Specialty Pharmacy Injectibles in MD Office |
| | HCM.MED.186: State of Illinois Drug Co-pay Appeals Process |
| | HCM.MED.187: Testosterone Replacement Therapy |
| | HCM.MED.193: Prozac Weekly Medication Authorization |
| | HCM.MED.193.010: Serafem |
| | HCM.MED.194: Lupon Therapy for Endometriosis |
| | HCM.MED.195: RSV (Respiratory Syncytial Virus) Prevention and Treatment |
| | HCM.MED.196: Enbrel Medication |
| | HCM.MED.196.010: Humira Medication |
| | HCM.MED.196.020: Remicade Medication |
| | HCM.MED.196.030: Orencia Medication |
| | HCM.MED.198: Growth Hormone Authorization - Child |
| | HCM.MED.200: Retin-A Authorization |
| | HCM.MED.201: Zyvox Medication Authorization |
| | HCM.MED.202: Pulmicort Respules Authorization |
| | HCM.MED.215: Emend |
| | HCM.MED.215.010: Apretitant |
| | HCM.MED.216: Zelnorm |
| | HCM.MED.216.010: Tegaserod |
| | HCM.MED.221: Growth Hormone Authorization - Adult |
| | HCM.MED.227: Xolar |
| | HCM.MED.227.010: Omalizumab |
| | HCM.MED.228: Fuzeon |
| | HCM.MED.228.010: Enfuvitride |
| | HCM.MED.231: Accolate |
| | HCM.MED.231.010: Zafirlukast |
| | HCM.MED.231.020: Singulair |
| | HCM.MED.231.030: Monteluskast |
| | HCM.MED.232: Restasis Medication |
| | HCM.MED.233: Rebetol Medication |
| | HCM.MED.234: Contraceptive Coverage |
| | HCM.MED.235: Zofran |
| | HCM.MED.235.010: Anzemet |
| | HCM.MED.235.020: Dolastron Mesylate |
| | HCM.MED.235.030: Granisetron Hydrochloride |
| | HCM.MED.235.040: Kytril |
| | HCM.MED.235.050: Ondansetron Hydrochloride |
| | HCM.MED.237: Drug Utilization Review |
| | HCM.MED.242: Influenza Vaccination Recommendations |
| | HCM.MED.253: Humira for Crohn's Disease |
| | HCM.MED.257: Byetta |
| | HCM.MED.257.010: Exenatide |
| | HCM.MED.258: Symlin |
| | HCM.MED.258.010: Pramlinitide |
| | HCM.MED.261: Actiq |
| | HCM.MED.261.010: Fentora |
| | HCM.MED.263: Nexavar and Sutent Medications |
| | HCM.MED.264: Ranexa Medication |
| | HCM.MED.264.010: Ranolazine Medication |
| | HCM.MED.265: Amitiza Medication |
| | HCM.MED.265.010: Lubiprostone Medication |
| | HCM.MED.270: Revlimid |
| | HCM.MED.270.010: Lenalidomide |
| | HCM.MED.274: Avastin Medication for Treatment of Macular Degeneration |
| | HCM.MED.274.010: Bevacizumab Medication for Treatment of Macular Degeneration |
| | HCM.MED.281: Statin Step Therapy |
| | HCM.MED.282: Qualaquin |
| | HCM.MED.283: Boniva and Forteo Injectibles |
| | HCM.MED.285: Januvia Medication |
| | HCM.MED.288: Tykerb (lapatinib ditosylate) Medication |
| | HCM.MED.289: New Medication Review Guidelines |
| | HCM.MED.294: Acthar Gel |
| | HCM.MED.297: Tekturna Medication |
| | HCM.MED.297.010: Aliskiren Medication |
| | HCM.MED.298: Intravenous Biphosphantes |
| | HCM.MED.298.010: Ibandronate "Boniva" |
| | HCM.MED.298.020: Zoledrenic Acid "Reclast" |
| | HCM.MED.299: Noxafil Medication |
| | HCM.MED.302: Supprelin L.A. (Histrelin Acetate) |
| |
Durable Medical Equipment and Supplies
|
| | HCM.DME.009: Knee Braces |
| | HCM.DME.015: Lift Chair |
| | HCM.DME.029: Thairapy Vests |
| | HCM.DME.040: Glucometers |
| | HCM.DME.042: Orthopedic Medical Equipment |
| | HCM.DME.055: Continuous Passive Motion Device |
| | HCM.DME.056: Insulin Infusion Pumps |
| | HCM.DME.057: Motorized Wheelchairs |
| | HCM.DME.058: C-PAP/BiPAP Masks and Supplies |
| | HCM.DME.065: Phototherapy - Light Boxes |
| | HCM.DME.094: Durable Medical Equipment |
| | HCM.DME.095: Diabetic, Ostomy and Urinary Supplies |
| | HCM.DME.096: Phototherapy -- Bilirubin |
| | HCM.DME.103: Aphakia: Coverage for Contact Lenses and Replacement |
| | HCM.DME.128: Wheelchair Replacements Parts |
| | HCM.DME.147: Van, Car or Home Lifts |
| | HCM.DME.149: Easy Stander |
| | HCM.DME.150: Braces, Custom make for Children with Cerebral Palsy |
| | HCM.DME.151: External Bone Growth Stimulator |
| | HCM.DME.152: Diabetic Test Strips |
| | HCM.DME.156: Contact Lens Coverage for Keratoconus |
| | HCM.DME.161: DME and Orthotics |
| | HCM.DME.190: C-PAP/Bi-PAP Machine |
| | HCM.DME.205: Bed - Hospital |
| | HCM.DME.206: Ambulatory Blood Pressure Monitoring |
| | HCM.DME.214: Breast Prosthesis and Prosthetic Bras |
| | HCM.DME.236: Anondyne Therapy |
| | HCM.DME.255: Dynamic Splinting Devices |
| | HCM.DME.262: Neocontrol Chair for Pelvic Floor Dysfunction |
| | HCM.DME.272: Pelvic Floor Electrical Stimulator (non-implantable) |
| | HCM.DME.273: Vitrectomy Support System |
| | HCM.DME.276: Continuous Glucose Monitoring System |
| | HCM.DME.277: Home Protime/INR Monitoring System |
| | HCM.DME.291: Surgical Dressings |
| | HCM.DME.292: Replacement DME |
| | HCM.DME.296: Electrical Stimulation Devices for Home Use |
| |
Surgery
|
| | HCM.SUR.006: Surgery Pre-certification |
| | HCM.SUR.011: Bariatric Surgery Pre-requisites |
| | HCM.SUR.019: Hysterectomy with or without BSO Abdominal or Vaginal Surgery |
| | HCM.SUR.034: Quick Authorization Policy |
| | HCM.SUR.034.020: Ablation/Excision Endometriosis, Laparoscopy |
| | HCM.SUR.034.030: Adenoidectomy |
| | HCM.SUR.034.040: Bunionectomy |
| | HCM.SUR.034.050: CABG Inpatient |
| | HCM.SUR.034.060: Carpal Tunnel Release |
| | HCM.SUR.034.080: Circumcision Quick Auth |
| | HCM.SUR.034.100: D & C |
| | HCM.SUR.034.110: D & C with Hysteroscopy |
| | HCM.SUR.034.120: Diskectomy-Cervical-Lumbar-Thoracic |
| | HCM.SUR.034.130: Ectropion Repair |
| | HCM.SUR.034.140: Entropion Repair |
| | HCM.SUR.034.150: Femoral Hernia Repair |
| | HCM.SUR.034.160: Ganglion Cyst |
| | HCM.SUR.034.170: Hammer Toe Repair |
| | HCM.SUR.034.180: Heel Spur Removal |
| | HCM.SUR.034.190: Hemorrhoidectomy |
| | HCM.SUR.034.200: Hydrocelectomy |
| | HCM.SUR.034.201: ICD (Cardiac Defibulator) Insertion |
| | HCM.SUR.034.210: Incisional/Ventral Hernia Repair |
| | HCM.SUR.034.220: Inguinal Hernia Repair |
| | HCM.SUR.034.230: Knee Arthroscopy or Arthrotomy |
| | HCM.SUR.034.240: Laminectomy-Cervical-Lumbar-Thoracic |
| | HCM.SUR.034.250: Laparoscopic Cholecystectomy |
| | HCM.SUR.034.260: Laparoscopy |
| | HCM.SUR.034.270: Lithotripsy |
| | HCM.SUR.034.280: Modified Radical Mastectomy |
| | HCM.SUR.034.290: Myringotomy |
| | HCM.SUR.034.300: Pacemaker Insertion |
| | HCM.SUR.034.301: Orchiopexy |
| | HCM.SUR.034.310: Partial Mastectomy/Lumpectomy |
| | HCM.SUR.034.311: Punctal Dilitation (Probe and Irrigate) |
| | HCM.SUR.034.360: Shoulder Rotator Cuff Repair - scopy or open |
| | HCM.SUR.034.370: Strabismus Repair |
| | HCM.SUR.034.380: Tonsillectomy |
| | HCM.SUR.034.390: Total Hip Replacement (inpatient) |
| | HCM.SUR.034.400: Total Knee Replacement (inpatient) |
| | HCM.SUR.034.410: Trigger Finger Release |
| | HCM.SUR.034.420: Umbilical Hernia Repair |
| | HCM.SUR.034.430: Varicocelectomy |
| | HCM.SUR.036: Cryosurgery of the Prostate |
| | HCM.SUR.117: Pre-certification of D&C |
| | HCM.SUR.126: Penile Prosthesis |
| | HCM.SUR.140: Orthognathic Surgery Pre-Requisites |
| | HCM.SUR.157: UPPP Authorization |
| | HCM.SUR.164: Breast Reconstruction |
| | HCM.SUR.166: Female Reduction Mammoplasty |
| | HCM.SUR.168: Circumcision |
| | HCM.SUR.178: Sclerotherapy |
| | HCM.SUR.181: Panniculectomy, Abdominal |
| | HCM.SUR.191: Varicose Vein Stripping Procedures |
| | HCM.SUR.192: IDET Procedure |
| | HCM.SUR.222: Prophylactic Mastectomy |
| | HCM.SUR.225: Prophylactic Oophorectomy |
| | HCM.SUR.259: Cochlear Implants |
| | HCM.SUR.260: ESWL for Plantar Fascitis Pre-requisites |
| | HCM.SUR.295: Dysfunctional Uterine Bleeding Treatment |
| | HCM.SUR.301: Insta Trak System VIT (Visual Imaging Technologies, Inc.) for Endoscopic Sinus Surgery |
| | HCM.SUR.303: Autologous Chondrocyte Transplantation |
| |
Smart Sheets
|
| | HCM.SMS.000: Smart Sheet Instructions |
| | HCM.SMS.001: Arthroscopy, Surgical, Knee Smart Sheet |
| | HCM.SMS.002: Acute Otitis Media Smart Sheet |
| | HCM.SMS.003: Cholecystectomy, Laparoscopic Smart Sheet |
| | HCM.SMS.004: Eustachian Tube Dysfunction Smart Sheet |
| | HCM.SMS.005: Hemilaminectomy, Lumbar +/-Discectomy/Foraminotomy Smart Sheet |
| | HCM.SMS.006: Hysterectomy and BSO, Abdominal or Vaginal Smart Sheet |
| | HCM.SMS.008: Ophthalmological Smart Sheet |
| | HCM.SMS.009: Otitis Media with Effusion Smart Sheet |
| | HCM.SMS.010: Recurrent Otitis Media Smart Sheet |
| | HCM.SMS.011: Total Joint Replacement (TJR), Hip Smart Sheet |
| | HCM.SMS.012: Worsening Acute Otitis Media Smart Sheet |
Providers
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