Prior Authorization Center | NALC HBP Member Support

Prior Authorization Center – NALC HBP

Prior authorization helps ensure that your health services and medications are safe, effective, and covered under your NALC Health Benefit Plan. This page offers clear guidance for members, providers, and anyone supporting NALC HBP members through the process.

Check Prior Authorization Vendors

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

Want the full details?

Review your brochure to understand what requires prior authorization.

Review the PSHB Brochure

How It Works

Most prior authorizations are submitted by your provider — but as a member, it's helpful to understand the steps:

The provider initiates a request with the correct vendor (listed below).

The request is reviewed using clinical and plan guidelines.

A decision is communicated to the provider (and often to the member).

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

Evernorth Health Services

Cigna LifeSOURCE

eviCore

CVS Caremark

CVS Specialty

NALC Health Benefit Plan

Optum

VENDOR / SERVICES	CONTACT NUMBER	WHO HANDLES / PROCESS
Gender Affirmation Surgeries	877-220-6252	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	877-220-6252	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	877-220-6252	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	877-220-6252	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	800-668-9682	Providers will initiate the process by supplying appropriate records to Cigna LifeSOURCE that warrants the procedure to be pre-authorized.
Cellular therapy	800-668-9682	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	877-220-6252	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	877-220-6252	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	800-294-5979	Providers must initiate the process with CVS Caremark by supplying medical records, diagnosis, and an explanation of why the prescription is required.
Compound drugs	800-933-6252	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	800-294-5979	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	800-237-2767	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	888-636-6252	The provider or member can initiate the process by contacting the NALC Health Benefit Plan to request review for approval.
Durable Medical Equipment	888-636-6252	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	888-636-6252	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	877-468-1016	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	877-468-1016	Providers are responsible to initiate the process and to supply documentation per Optum's request.

Cigna

CVS Caremark

CVS Specialty

VENDOR / SERVICES	CONTACT NUMBER	WHO HANDLES / PROCESS
Air Ambulance Transport not related to a medical emergency or accidental injury	855-511-1893	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	855-511-1893	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	855-511-1893	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	855-511-1893	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	855-511-1893	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	855-678-0051	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	855-511-1893	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	855-511-1893	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	855-511-1893	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	855-511-1893	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	855-511-1893	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	855-511-18933	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	855-511-18933	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	800-294-5979	Provider will contact CVS to start the approval process while also submitting medical records and diagnosis explaining the need for the medicine.
Compound drugs	800-933-6252	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	800-294-5979	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.	800-237-2767	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.

Looking for something else?

Additional Forms

Need Help? Let’s Connect

PSHB Members

Customer Service: 888-636-6252

Frequently asked Questions

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.

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