Prior authorization required for listed drugs

All drugs listed on the policy require prior authorization; submit the PA using the HCPCS/J-code shown for the drug and route the request to the reviewer indicated (ESI, CCUM, eviCore) or to WPS if the external reviewer cannot complete the review.

• Include the drug name and appropriate HCPCS/J-code when submitting the PA.
• Use reviewer contact 1-800-475-1954 for ESI/CCUM/eviCore or WPS at 1-800-333-5003 when routing as directed.

PA required for listed drugs

Prior authorization is required for each drug listed; the policy indicates the assigned reviewer (ESI, CCUM, eviCore) and the HCPCS code to use per drug entry.

• Follow the reviewer assignment shown next to each drug (e.g., ESI = option 1, CCUM = option 2, eviCore = option 3).
• If your group's PBM is not ESI through WPS, submit to that PBM as instructed.

Prior authorization required

All drugs in these sections require prior authorization; if ESI, CCUM, or eviCore cannot complete the delegated review, submit the PA to WPS for evaluation.

• Route medical-benefit submissions using the HCPCS/J-code provided and the reviewer specified for that drug.
• If the external reviewer cannot complete the review, submit to WPS at 1-800-333-5003.

Prior authorization requirement

Every drug listed in these chunks requires prior authorization and should be routed to the reviewer indicated (ESI/CCUM/eviCore) shown for each drug entry.

• Follow reviewer routing options: ESI (option 1), CCUM (option 2), eviCore (option 3).
• If the designated vendor cannot complete the review, submit to WPS for evaluation.

Prior authorization required

Submit prior authorization requests for the drugs in these segments to the designated reviewer (ESI, CCUM, eviCore, or WPS) shown next to each drug; if an external reviewer cannot complete the review, escalate to WPS.

• Use the phone number 1-800-475-1954 to contact ESI/CCUM/eviCore; use 1-800-333-5003 for WPS.
• Provide the HCPCS code and benefit type (P or M) when submitting.

All listed drugs require PA

Prior authorization is required for each listed drug; for medical-benefit drugs submit using the HCPCS/J-code shown and for pharmacy-benefit drugs follow PBM routing indicated in the entry.

• Medical benefit claims: bill using the HCPCS/J-code provided for facility/provider billing.
• Pharmacy benefit drugs: submit to the PBM indicated (e.g., ESI) or the group's PBM per policy notes.

PA required; reviewer routing

PA is required for the drugs shown; route requests to the named reviewer vendor (ESI, CCUM, eviCore) or submit to WPS when the PBM cannot complete the review.

• Use reviewer routing as listed for each drug entry.
• If delegated reviewer cannot complete review, submit to WPS at 1-800-333-5003.

PA required; codes and reviewer assignment

Prior authorization is required for each listed drug; each entry includes HCPCS/J/Q/C codes and the assigned reviewer (ESI, CCUM, or eviCore) to which the PA must be submitted.

• Include the HCPCS/J/Q/C code shown in the drug entry when submitting the PA.
• Route the PA to the reviewer vendor listed for that drug (contact 1-800-475-1954).

PA required; submit to delegated reviewer

All drugs in these chunks require prior authorization; submit requests to the delegated reviewer indicated (ESI, CCUM, eviCore) or to WPS if the delegated reviewer cannot complete the review.

• Follow delegated reviewer instructions per drug entry.
• If reviewer cannot complete review, forward PA to WPS for evaluation.

Prior authorization required

All drugs listed in these chunks require prior authorization; reviewer assignment (ESI, CCUM, eviCore, or WPS) is indicated for each drug entry and must be followed when submitting the PA.

• Benefit Type field indicates Pharmacy (P) or Medical (M); route accordingly.
• If the external reviewer cannot complete the review, submit to WPS.

Prior authorization required

Prior authorization is required for each drug entry; submit requests to the reviewer listed for that drug (ESI, CCUM, eviCore) or to WPS if external reviewers cannot complete the review.

• Include the HCPCS code shown and specify oncology vs non-oncology indication so the correct reviewer is engaged.
• Use external reviewer contact 1-800-475-1954 or WPS at 1-800-333-5003 as needed.

PA required for listed drugs

Prior authorization is required for each drug entry; submit the PA to the reviewer listed for that drug (ESI, CCUM, eviCore, or WPS) using the contact routing provided in the policy.

• Provide drug name, HCPCS/J-code, and benefit type when submitting the request.
• If the delegated reviewer cannot complete the review, escalate to WPS for evaluation.

PA required; reviewer contacts

All drugs listed require prior authorization; the document provides reviewer phone numbers (ESI/CCUM/eviCore and WPS) to request PA and indicates which reviewer to contact per drug.

• Primary reviewer contact for delegated reviewers: 1-800-475-1954.
• WPS PA phone: 1-800-333-5003.

PA required; submit to delegated reviewer

Prior authorization is required for the drugs shown; submit PA requests to the delegated reviewer (ESI, CCUM, eviCore) or to WPS when the reviewer cannot complete the review.

• Use the HCPCS code listed for the drug when submitting medical-benefit requests.
• If delegated reviewer cannot complete review, send the PA to WPS for evaluation.

PA required; reviewer and code listed

Each listed drug requires prior authorization; the entry includes HCPCS/J-codes and the reviewer contact (ESI, CCUM, eviCore) to which the PA must be submitted.

• Include HCPCS/J-code from the drug entry in the PA submission.
• Route to the reviewer shown for that drug (contact 1-800-475-1954) or to WPS if necessary.

How to obtain PA/step therapy criteria

Step therapy and prior authorization criteria for drugs reviewed by Express Scripts or Care Continuum are available by calling 1-800-475-1954; eviCore criteria are available at evicore.com.

• Call 1-800-475-1954 to speak with a prior authorization specialist for ESI/CCUM criteria.
• For eviCore guidelines, go to https://www.evicore.com/provider/clinical-guidelines and search 'WPS Health Insurance'.

PBM submission note

If your group uses a PBM other than Express Scripts through WPS, submit prior authorization requests to that PBM; this includes pharmacy drugs that may otherwise be reviewed by ESI or eviCore.

• When a different PBM is in place, follow that PBM's PA submission process for pharmacy-benefit drugs.
• If the external reviewer cannot complete the review, submit the PA to WPS for evaluation.

PBM routing: submit to the group's PBM when not ESI

If your group's PBM is not Express Scripts through WPS, submit PAs to that PBM; pharmacy drugs reviewed by ESI or eviCore may be handled by those vendors when they are the group's PBM.

• Confirm which PBM is responsible for pharmacy-benefit reviews before submitting a PA.
• When in doubt, contact WPS for routing instructions.

PBM routing note

If your group's PBM is not Express Scripts through WPS, submit prior authorization requests to that PBM for pharmacy-benefit drugs; entries in this policy note that some pharmacy drugs may be reviewed by ESI or eviCore when those vendors are the PBM.

• Verify the PBM responsible for the member's coverage before submitting a pharmacy PA.
• If delegated reviewer cannot complete the review, submit to WPS for evaluation.

Evidence reviewers use in PA decisions

Reviewers use the patient's medical records, FDA labeling, peer‑reviewed literature, and evidence‑based guidelines when making prior authorization decisions.

• Provide medical records describing the patient's condition and prior treatments with the PA submission.
• FDA labeling and relevant literature may be requested during review.

AHH fax for AETNA network groups

For WPS Powered by Auxiant groups using the AETNA network, fax medical notes for recommended medical necessity review of medical‑benefit drugs to American Health Holdings (AHH) at 608-273-4554 prior to administration.

• Fax medical documentation to AHH at 608-273-4554 for AETNA network medical‑benefit drugs.
• A medical necessity review is recommended even when a separate PA is not required under the medical benefit.

Where to submit PA

Submit prior authorization requests to the reviewer listed for each drug (ESI, CCUM, or eviCore); if those reviewers cannot complete the review, submit the PA to WPS for evaluation.

• Use reviewer contact 1-800-475-1954 for ESI/CCUM/eviCore and 1-800-333-5003 for WPS.
• Include drug name, HCPCS/J-code, benefit type, and indication when submitting.

Where to submit PA

Submit PA requests to the reviewer shown for each drug or to WPS if external reviewers cannot complete the review; follow the contact numbers and routing indicated in the drug entry.

• Contact external reviewers at 1-800-475-1954; contact WPS at 1-800-333-5003 if needed.
• If a PBM other than ESI is in effect, submit to that PBM for pharmacy-benefit drugs.

Where to submit PA

Submit prior authorization requests to the designated reviewer shown for each drug using the contact numbers listed; if the PBM is not ESI through WPS or the external reviewer cannot complete the review, submit to WPS for evaluation.

• Provide benefit type (P or M) and HCPCS code when submitting.
• When the external reviewer is unable to review, route to WPS at 1-800-333-5003.

Where to submit PA

Submit prior authorization requests to the reviewer indicated for each drug using the phone numbers provided; if the PBM or delegated reviewer cannot complete review, submit the PA to WPS for evaluation.

• Primary reviewer phone: 1-800-475-1954 (ESI/CCUM/eviCore).
• WPS phone: 1-800-333-5003 for escalations or when reviewers cannot complete review.

Submission routing and contact

Submit prior authorization requests to the reviewer vendor listed for the drug (ESI, CCUM, eviCore) or to WPS if the vendor cannot complete the review; vendor contact numbers are provided in the policy.

• Include the HCPCS/J-code and indication to ensure correct routing.
• If the vendor is unable to complete review, forward to WPS for evaluation.

Submission routing and contact

Provider must submit PA requests to the listed reviewer (ESI, CCUM, eviCore) or to WPS if the PBM cannot complete the review; contact numbers for reviewers and WPS are provided.

• When submitting, specify drug name, HCPCS code, benefit type, and indication.
• If your group's PBM differs from ESI, follow that PBM's submission instructions.

Submission routing and contact

Providers must submit PA requests to the referenced reviewer (ESI, CCUM, or eviCore) or to WPS if the reviewer cannot complete the review; contact numbers are provided in the policy.

• Use 1-800-475-1954 to reach delegated reviewers; use 1-800-333-5003 for WPS escalations.
• Include the HCPCS/J-code and benefit type in submissions.

Where to submit PA

Submit PA to the listed reviewer (ESI, CCUM, eviCore) or to WPS if the delegated reviewer cannot complete the review; contact numbers are provided in the policy.

• Follow the reviewer assignment shown next to each drug entry.
• Escalate to WPS when reviewers cannot complete the review.

Submission pathway when delegated reviewer cannot complete review

If ESI, CCUM, or eviCore cannot complete the delegated review, submit the prior authorization request to WPS for evaluation.

• Contact WPS at 1-800-333-5003 for submission when external reviewers cannot complete review.
• Include the original reviewer information and documentation when resubmitting to WPS.

Where to submit PA

Submit PA requests to the designated reviewer listed for each drug; if the reviewer cannot complete the review, submit the PA to WPS for evaluation using the contact information provided.

• Provide drug name, HCPCS code, benefit type, and indication with the request.
• Use 1-800-475-1954 for delegated reviewers and 1-800-333-5003 for WPS.

Where to submit PA

Submit prior authorization requests to ESI, CCUM, or eviCore as indicated for each drug; if those reviewers cannot complete the review, submit the PA to WPS for evaluation.

• Include HCPCS/J-code and whether the indication is oncology or non‑oncology to route correctly.
• If the delegated reviewer cannot complete the review, escalate to WPS.

Submit to appropriate reviewer or WPS

Submit PA requests to ESI, CCUM, or eviCore as indicated; if those reviewers cannot complete the review, submit to WPS for evaluation.

• Contact 1-800-475-1954 for delegated reviewer assistance; contact WPS at 1-800-333-5003 for escalations.
• Provide required submission details shown in the policy (drug name, HCPCS code, benefit type).

Submit to appropriate reviewer or WPS

When external vendors cannot complete the review, providers must submit the PA to WPS for evaluation; contact numbers for ESI/CCUM/eviCore (1-800-475-1954) and WPS (1-800-333-5003) are provided.

• Escalate to WPS if delegated reviewer cannot complete review.
• Include original reviewer details and all supporting documentation when resubmitting.

Required submission details

For each listed drug include the drug name, appropriate HCPCS/J-code when applicable, benefit type (Pharmacy or Medical), and indicate if the request is for an oncology or non‑oncology indication so the correct reviewer can be engaged.

• Provide HCPCS/J-code and benefit type P or M on the submission.
• State the indication (oncology vs non‑oncology) to ensure proper routing.

Where to submit PA

Submit PA requests to the designated reviewer (ESI, CCUM, or eviCore) or to WPS if the PBM cannot complete the review.

• Confirm which reviewer is responsible for the drug and use the contact provided in the policy.
• If the PBM cannot complete review, forward to WPS for evaluation.

Medical necessity and experimental exclusions

Coverage of services is subject to medical necessity; services deemed experimental, investigational, or unproven will not be covered under the policy.

• Ensure requested treatment meets the plan's medical necessity criteria.
• Experimental or investigational services are not eligible for coverage.

PA required

Lack of a prior authorization (PA) for any drug listed on this policy will trigger the need for review; drugs on the list require a PA before coverage is approved.

• Do not administer or bill for listed drugs without obtaining the required PA.
• If PA is not obtained, coverage may be denied.

PA requirement

Failure to obtain prior authorization (PA) for any drug on the list may result in denial of coverage; providers must secure the PA and submit as directed.

• Claims submitted without required PA are at risk for denial.
• Follow the reviewer routing and submission requirements to avoid denials.

PA required for listed drugs

Failure to obtain prior authorization (PA) for any drug on the list will risk denial; all drugs on this list require a PA and must be submitted to the appropriate reviewer or to WPS if reviewers cannot complete the review.

• Ensure PA is approved before dispensing or administering listed drugs.
• If the delegated reviewer cannot complete review, submit to WPS to avoid processing delays or denial.

PA required for listed drugs

Failure to obtain prior authorization for any drug on the list will risk denial, since the document states all drugs on this list require a PA.

• Confirm PA approval prior to treatment.
• Follow PBM routing instructions where applicable.

All listed drugs require PA

Failure to obtain prior authorization for any drug on the list may result in denial; all drugs on this list require a PA and must be submitted to the designated reviewer or to WPS if the vendor cannot complete review.

• Use HCPCS/J-codes for medical‑benefit submissions as shown.
• Route pharmacy‑benefit drugs per PBM assignment to avoid denials.

PA required

Failure to obtain prior authorization for any drug listed may lead to denial of coverage; all drugs on this list require a PA before approval.

• Obtain PA prior to providing therapy to prevent claim denials.
• If external reviewer cannot complete review, submit to WPS for evaluation.

PA required for listed drugs

No PA will be processed without prior authorization; all drugs on this list require a PA and, if ESI, CCUM, or eviCore cannot complete the review, submit to WPS for evaluation.

• Submit PA to the delegated reviewer first; if they cannot complete review, forward to WPS.
• Claims without required PA are subject to denial.

Prior authorization required

Failure to obtain prior authorization will risk denial since 'All drugs on this list require a PA.'

• Confirm PA approval before administering or billing for listed drugs.
• Escalate to WPS if delegated reviewer cannot complete the review.

PA required

Claims for any drug on this list will require prior authorization; failure to obtain PA may result in denial of coverage.

• Ensure PA is obtained and approved prior to service.
• Provide all requested documentation to the reviewer to support medical necessity.

PA required

No prior authorization will be approved for listed drugs without submission to the appropriate reviewer (ESI, CCUM, eviCore) or to WPS when those reviewers cannot complete review.

• Submit to the reviewer specified for the drug; if unable, submit to WPS for evaluation.
• Provide HCPCS/J-code and indication to the reviewer.

PA required

Failure to obtain prior authorization (PA) for any drug on this list may lead to denial; all drugs on this list require a PA.

• Obtain PA prior to treatment to reduce risk of denial.
• Follow the reviewer routing specified in the policy.

PA required for listed drugs

Failure to submit a required prior authorization (PA) for any drug on the listed pages may result in denial of coverage or claim processing issues; all drugs on this list require a PA.

• Include required documentation with the PA to avoid processing delays.
• If the reviewer cannot complete the review, resubmit to WPS.

PA required for listed drugs

Failure to submit a prior authorization (PA) for any drug on this list will risk denial of coverage; all drugs on this list require a PA and must be submitted as directed.

• Submit PAs following the routing and contact information in the policy.
• Ensure HCPCS/J-code and indication are clearly stated in submissions.