Catholic Health Initiatives (CHI) Members

Click here for Services Requiring Pre-Authorization.

QualChoice Members

Services Requiring Pre-Authorization.

Search or browse by service type to see services requiring pre-authorization.

Please also check the QualChoice Coverage Policies if you do not find a specific procedure listed here.

These services require Pre-Authorization.Click to View Medical PolicyJ-Codes
Actemra (Tocilizumab) J3262
Acthar J0800
Actimmune J1830, J9216
Adagen J2504
Adcetris J9042
Adcirca
Adempas
Advair (Fluticasone/Salmeterol
Advate J7192
Adynovate (Pegylated Antihemophilic Factor) J7207
Afinitor (Everolimus)
Aldurazyme J1931
Alecensa (Alectinib)
Alferon N
J9215
Alpha 1 - Antitrypsin Inhibitor Therapy
Alphanate
J7186
AlphaNine SD J7193
Alprostadil J0270
Alunbrig (Brigatinib)
Ampyra
Androgel 1.62% (Testosterone Gel)
Antihemohilic Factor, Generic J7182
Aralast
J0256
Aripiprazole
Astagraf XL
Aubagio
Avastin J9035
Axiron
Azelex Cream
Bavencio (Avelumab)
Bebulin VH J7194
Beleodaq
Benefix
J7195
Benicar/Benicar HCT
Benlysta (Belimumab) J0490
Bivigam J1599
Blincyto C9449
Boniva
Bosulif
Botox (Inj.: Botulinum Toxin Type A, per unit) J0585
Breo Ellipta (Fluticasone/Vilanterol)
Briviact
Buprenorphin/Naloxone
Bydureon
Byetta
Caprelsa
Carbaglu
Carimune NF J1566
Caverject J0270
Cayston
Cerdelga
Ceredase J0205
Cerezyme J1785
Chantix (Varenicline)
Cholbam
Cialis
Cimzia J0718
Cladribine
J9065
Coagadex (Coagulation Factor X (Human)) J7175
Cometriq
Corifact J7180
Cosentyx
Cotellic (Cobimetinib)
Cresemba C9456
Cuvitru (Immune Globulin)
Cycloset
Cyramza C9025
Cystagon (Cysteamine)
Cytogam (Cytomegalovirus Immune Globulin (CMV-IGIV))
J0850
Daliresp
Darzalex (Daratumumab) J9145
Daytrana J0718
Diclofenac Gel 3%
Differin Cream/Gel
Dificid
Diovan/Diovan HCT (Valsartan & Valsarta/HCTZ)
Duavee (Bazedoxifene/Conjugated Estrogens)
Dysport J0586
Edarbi/Edarbyclor (Azilsartan & Azilsatan/Chlorthalidone)
Edex J0270
Egrifta
Elaprase
J1743
Elelyso J3060
Emcyt (Estramustine)
Empliciti (Elotuzumab) J9176
Enablex (Darifenacin)
Enbrel J1438
Entyvio J3380
Epaned
Epclusa (Sofosbuvir/Velpatasvir)
Erbitux J9055
Erivedge
Erwinaze J9019
Esbriet (Pirfenidone)
Eucrisa
Exjade
Eylea J0178
Fabrazyme J0180
Factor Products for Bleeding Disorders
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QualChoice Network Medical Providers: You will receive verbal approval when requesting pre-authorization. Please inform your patient at that time that the request has been approved. Thank you.

Pre-authorization is the decision to cover a planned medical procedure, prescription drug or medical device. Pre-authorization is not a promise of payment for care or services.

Items with an asterisk (*) may be reviewed after the service has been performed. All others must be approved before services are performed. The member must get pre-authorization for any services outside the network noted on their ID card.

Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.