Referrals & Prior Authorization
You can get many services without a referral from your Primary Care Provider (PCP). This means that your PCP does not need to arrange or approve these services for you. You can search for participating health partners using the Find a Doctor/Provider tool and schedule an appointment yourself. You can also check your provider directory for a list of participating health partners who offer these services.
Services that Require a Referral
Most of the time, a referral is not needed. You can visit specialists as you need them. Some services and tests need a referral. That means you must get an OK from your provider before you can get the service. Your provider will do one of the following:
- Arrange the services for you
- Give you a written OK to take with you when you get the service
- Tell you how to get the service
Your doctor will work with us to get a prior authorization for services that need one. For example, some procedures and most inpatient hospital stays require prior authorization. Although your provider should get a prior authorization from us, you may want to ensure that your provider has received our approved prior authorization.
Many other services do not need a prior authorization. You do not need one to see your PCP or most specialists. You don’t need one for routine lab work, x-rays or many outpatient services either. Your PCP will tell you when you need these types of care.
You can download the Marketplace Prior Authorization List here:
- 2022 Prior Authorization List (coming soon)
- 2021 Prior Authorization List
Prior Authorization for Prescriptions
For some drugs, we require that your doctor send us some information. This is called a prior authorization request. It tells us why a certain drug and/or a certain amount of a drug is needed. We must approve the request before you can get the drug covered by your plan.
You can find out if a drug requires prior authorization by reviewing the CareSource Marketplace Drug Formulary on the Drug Formulary page. Medications billed on the medical benefit may also require prior authorization. Please check the Authorization Requirements for Medications on the Medical Benefit.
We may not approve a prior authorization request for a drug. If we don’t, we will send you information about how you can appeal our decision.
Opioid drugs must meet the following prior authorization requirements:
- Less than 90 days of therapy in the last 365 days
- No concurrent therapy with benzodiazepines
- All extended release opioids require prior authorization
Services Outside of Network
Routine care and services that you get outside of the CareSource network are not normally considered covered services. However, services will be covered when you receive them from a non-network provider connected to an in-network hospital (for example, an anesthesiologist’s services performed during a covered surgery).
Other services may need a prior authorization from us, including services from a non-network provider when there is no in-network provider for that particular type of care.
Continuity of Care
We are here to help you continue and coordinate your current medically necessary care when you join CareSource. If you have health care services that were scheduled before you joined our plan, call us right away. Call us if you have a health condition that we need to be aware of so we can ensure a smooth transition; for example, if you need surgery or are pregnant. We want to help you get the care you need.