Prior Authorization for Covered Services

Covered Services

You do not need a referral from your PCP for the following services:

  • Emergency care
  • Behavioral Health issues
  • OB/GYN services
  • Dental services

The care listed below will be covered through B – UFC/ALTCS. Some services may have limitations and/or require a prior authorization, contact your Case Manager or the Customer Care Center for more information:

  • Ambulance for emergency care
  • Behavioral Health Care
  • Pregnancy care
  • Case management
  • Checkups for children, pregnant women, QMB, and SMI members
  • Children's services including routine dental care
  • Chiropractic services for children and QMB
  • Dialysis
  • Diet and health teaching
  • Disease Management
  • Durable Medical Equipment (DME)
  • Emergency or Urgent Care medical treatment
  • Eyeglasses or contacts for children, or adults only after cataracts are removed
  • Family planning / birth control
  • Health care services through screenings, diagnosis and medically needed treatments for members 21 years of age or older
  • Hospice care
  • Home and Community Base Services (HCBS) and Assisted Living Facilities (ALF)
  • Hospital care
  • Lab work and x-rays
  • Limited dental services (members over the age of 20)
  • Medical tests
  • Medically needed foot care done by a licensed Podiatrist. A Podiatrist may provide foot care for members when ordered by a PCP.
  • Medicine from the approved drug list, the B – UFC/ALTCS Drug Formulary
  • Organ transplants
  • Orthotics
  • PCP office visits
  • Preventative and routine gynecological services for female members (no referral needed)
  • Private Nursing Care
  • Transportation to health care visits
  • Speech, Physical and Occupational Therapies
  • Second opinions: You have the right to have a second opinion from a qualified health care professional within the network. If one is not available in the network, you have the right to ask for a second opinion outside the network at no cost to you
  • Skilled nursing home care
  • Supplies and equipment, including B – UFC/ALTCS Drug Formulary diabetic testing equipment and supplies
  • Well-child checkups including dental, hearing, shots and vision care

Important Information Related to RSV and Synagis

B – UFC/ALTCS is pausing prior authorization requirements this season for Synagis® (palivizumab). Effective November 15, 2022, prior authorization for Syangis is not required. This is effective for the remainder of the 2022-23 RSV season.