What is Prior Authorization?
Some services and prescriptions need approval before they are covered — this is called prior authorization. The process helps determine if the treatment is medically necessary and aligned with your benefits.
It’s often required for things like:
- High-cost or specialty medications
- Outpatient surgeries
- Durable medical equipment (DME)
- Some contraceptive devices or medications
- High-Tech radiology
How It Works
Most prior authorizations are submitted by your provider — but as a member, it's helpful to understand the steps:
01
The provider initiates a request with the correct vendor (listed below).
02
The request is reviewed using clinical and plan guidelines.
03
A decision is communicated to the provider (and often to the member).
04
If denied, appeal rights are available.
Note for Providers: Contact information and forms are listed by service type in the section below. Make sure you use the correct vendor based on the member’s plan and the service being requested.
Prior Authorization For Postal (PSHB) Members
|
VENDOR / SERVICES |
CONTACT NUMBER |
WHO HANDLES / PROCESS |
|---|---|---|
|
Gender Affirmation Surgeries |
Providers will initiate the process by supplying appropriate records and documents to Evernorth Health Services, showing medical necessity that the procedure should be pre-authorized. |
|
|
Genetic testing |
Providers will initiate the process by supplying appropriate records and documents to Evernorth Health Services, showing medical necessity that the genetic test should be pre-authorized. |
|
|
Inpatient Hospital stays |
It is the members responsibility, but the provider or member can initiate the process by supplying medical records to Evernorth Health Services showing the medical necessity of an inpatient admission. Failure to pre-certify could result in a $500 penalty, which is the patient's responsibility. |
|
|
Spinal Surgeries |
Providers will initiate the process by supplying appropriate records and documents to Evernorth Health Services showing medical necessity that the procedure should be approved / pre-authorized. |
|
VENDOR / SERVICES |
CONTACT NUMBER |
WHO HANDLES / PROCESS |
|---|---|---|
|
Organ/tissue transplants and donor expenses |
Providers will initiate the process by supplying appropriate records to Cigna LifeSOURCE that warrants the procedure to be pre-authorized. |
|
|
Cellular therapy |
Providers will initiate the process by supplying appropriate records to Cigna LifeSOURCE that warrants the therapy to be pre-authorized. |
|
VENDOR / SERVICES |
CONTACT NUMBER |
WHO HANDLES / PROCESS |
|---|---|---|
|
Radiology and outpatient imaging services such as CT/CAT, MRI, MRA, NC, or PET scans |
Providers will initiate the process by supplying medical records to eviCore and information that would warrant the need for high-tech radiology. |
|
|
Musculoskeletal procedures (MSK) such as orthopedic surgeries and injections |
Providers will initiate the process by supplying medical records to eviCore and information that would warrant the need for an orthopedic surgery or injections. |
|
VENDOR / SERVICES |
CONTACT NUMBER |
WHO HANDLES / PROCESS |
|---|---|---|
|
Anti-narcolepsy, ADD/ADHP, certain analgesics, certain opioids, 510k dermatological products and artifical saliva |
Providers must initiate the process with CVS Caremark by supplying medical records, diagnosis, and an explanation of why the prescription is required. |
|
|
Compound drugs |
Providers must initiate the process with CVS Caremark by supplying medical records, diagnosis, and an explanation of why the prescription is required. |
|
|
Weight loss drugs |
Providers must initiate the process with CVS Caremark by supplying medical records, diagnosis, and an explanation of why the prescription is required. |
|
VENDOR / SERVICES |
CONTACT NUMBER |
WHO HANDLES / PROCESS |
|---|---|---|
|
Specialty drugs, including biotech, biological, biopharmaceutical, and oral chemotherapy drugs |
Providers must initiate the process with CVS Caremark by supplying medical records, diagnosis, and an explanation of why the prescription is needed. |
|
VENDOR / SERVICES |
CONTACT NUMBER |
WHO HANDLES / PROCESS |
|---|---|---|
|
Air Ambulance Transport not related to a medical emergency or accidental injury |
The provider or member can initiate the process by contacting the NALC Health Benefit Plan to request review for approval. |
|
|
Durable Medical Equipment |
The provider or member can initiate the process by supplying documentation to our Cost Containment Department, which warrants the need for the specific durable medical equipment. |
|
|
Gene Therapy |
The provider or member can initiate the process by contacting our Case Management Department and they in turn would contact the Gene Therapy team. The Gene Therapy team will then coordinate with the provider who is responsible to supply any required documents to have the gene therapy prior authorized. |
|
VENDOR / SERVICES |
CONTACT NUMBER |
WHO HANDLES / PROCESS |
|---|---|---|
|
Applied Behavioral Analysis (ABA) therapy |
The member would locate an in-network ABA therapist. Once a therapist has been selected they would initiate the prior authorization request by supplying the appropriate medical documentation. |
|
|
Mental Health and substance disorder care |
Providers are responsible to initiate the process and to supply documentation per Optum's request. |
|
VENDOR / SERVICES |
CONTACT NUMBER |
WHO HANDLES / PROCESS |
|---|---|---|
|
Air Ambulance Transport not related to a medical emergency or accidental injury |
The provider will initiate the process by supplying any required medical documentation, showing medical necessity, and the need for the transport to be pre-authorized. |
|
|
Applied Behavioral Analysis (ABA) therapy |
The provider will initiate the process by supplying any required medical documentation, showing medical necessity, and the need for ABA therapy to be pre-authorized. |
|
|
Cellular therapy |
The provider will initiate the process by supplying any required medical documentation, showing medical necessity, and the need for cellular therapy to be pre-authorized. |
|
|
Durable medical equipment |
The provider will initiate the process by supplying any required medical documentation, showing medical necessity, and the need for durable medical equipment to be approved. |
|
|
Gender affirmation surgery |
The provider will initiate the process by supplying any required medical documentation, showing medical necessity, and the need for the procedure(s) to be pre-authorized. |
|
|
Gene therapy |
The provider will initiate the process by supplying any required medical documentation, showing medical necessity, and the need for gene therapy to be pre-authorized. |
|
|
Genetic testing |
The provider will initiate the process by supplying any required medical documentation, showing medical necessity, and the need for genetic testing to be pre-authorized. |
|
|
Inpatient Hospital stays |
The provider will initiate the process by supplying any required medical documentation showing medical necessity, and the need for the inpatient admission to be pre-authorized. |
|
|
Mental health and substance use disorder care |
The provider will initiate the process by supplying any required medical documentation, showing medical necessity, and the need for certain mental health and substance use disorder services to be pre-authorized. |
|
|
Musculoskeletal procedures, such as orthopedic surgeries and injections |
The provider will initiate the process by supplying any required medical documentation, showing medical necessity, and the need for an orthopedic surgery or injections to be pre-authorized. |
|
|
Organ/tissue transplants and donor expenses |
The provider will initiate the process by supplying any required medical documentation, showing medical necessity, and the need for a procedure to be pre-authorized. |
|
|
Radiology and outpatient imaging services such as CT/CAT, MRI, MRA, NC, or PET scans |
The provider will initiate the process by supplying any required medical documentation, showing medical necessity, and the need for high-tech radiology (imaging) to be pre-authorized. |
|
|
Spinal surgeries |
The provider will initiate the process by supplying any required medical documentation, showing medical necessity, and the need for a spinal procedure to be pre-authorized. |
|
VENDOR / SERVICES |
CONTACT NUMBER |
WHO HANDLES / PROCESS |
|---|---|---|
|
Anti-narcolepsy, ADD/ADHP, certain analgesics, certain opioids, 510k dermatological products and artificial saliva |
Provider will contact CVS to start the approval process while also submitting medical records and diagnosis explaining the need for the medicine. |
|
|
Compound drugs |
Provider will contact CVS to start the approval process while also submitting medical records and diagnosis explaining the need for the medicine. |
|
|
Weight loss drugs |
Provider will contact CVS to start the approval process while also submitting medical records and diagnosis explaining the need for the medicine. |
|
VENDOR / SERVICES |
CONTACT NUMBER |
WHO HANDLES / PROCESS |
|---|---|---|
|
Specialty drugs, including biotech, biological, biopharmaceutical, and oral chemotherapy drugs. |
Provider will initiate the process by contacting CVS and completing the Prior Authorization form while also providing medical documentation. |
Forms & Downloads
If you're a provider or a member preparing for a prior authorization, the following forms are required for the most common requests. All forms are fillable PDFs and can be submitted by fax or electronic provider portals where applicable.
- Surgical Prior Authorization Request (PDF)
- DME Prior Authorization Request (PDF)
- Contraceptive Zero Copay Exception Form
Looking for something else?
FAQs for New Members
Prior authorization is a review process where the Plan checks if a service or medication is medically necessary before it’s covered. It helps ensure you receive safe, effective, and appropriate care.
Some surgeries, high-cost imaging, specialty medications, and certain therapies may require approval first. You can check the current list in the Prior Authorization Center, our official Plan brochure, or by calling our Customer Service Department at 888-636-6252.
No. Emergency care never requires prior authorization. You should seek emergency treatment immediately when needed.
Most requests are reviewed quickly, often within a few business days. Urgent requests are handled faster.
You have the right to appeal. Instructions for appeals are included in your denial letter. If you have questions you can contact our Customer Service Department 888-636-6252.