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Referals and Preapproval

Referrals

For some services, you’ll need a referral from your primary care provider (PCP) before you can get them. A referral means your PCP sends you to another provider for services your PCP can’t provide. When you need a referral, your PCP will send you to a provider in our plan. You need a referral to:

  • See specialists
  • Get nonemergency care at a hospital
  • See other providers for medicines your PCP can’t give you

Some services don’t need a referral from your PCP. These include:

  • Family planning (For these services, you may see a provider outside our plan.)
  • Emergency services
  • Behavioral health and substance use disorder services

To learn more about referrals, see your member handbook.

Preapproval (prior authorization)

Some treatment, care or services may need our approval before your provider can give them to you. This is called preapproval. Your provider will work directly with us to get the approval. The following require preapproval:

  • Most surgeries, including some outpatient surgeries
  • All elective and nonurgent inpatient services and admissions
  • Certain prescriptions
  • Certain durable medical equipment, including prosthetics and orthotics
  • Hearing aids
  • Home health services
  • Hospice services
  • Rehabilitation therapy (physical, occupational, respiratory and speech therapies)
  • Sleep studies
  • Out-of-area or out-of-network care except in an emergency and for family planning
  • Advanced imaging (things like MRAs, MRIs, CT scans and CTA scans)

This list is subject to change without notice and isn’t a complete list of covered plan benefits. Learn more about your benefits by:

  • Reading your member handbook
  • Calling Member Services with questions about specific services