REMINDER: Submitting referrals to non-participating providers - A referral may not be submitted prior to 10/1/2023. Please visit the US Family Health Plan Referral page for frequently asked questions on the referral process.
Authorizations and Referrals
Generations Advantage Part B Step Therapy: Drugs & Biologics Changes for March 1, 2023
Provider Portal User Guide (PDF) | Latest as of October 2023
- Prior authorization is required for all Step Therapy drugs, preferred and non-preferred.*
- *The only preferred drugs not requiring authorization are:
- Synvisc®, Synvisc-One®, Orthovisc®, and Monovisc®
- Avastin® is preferred for ocular indications only and does not require authorization
- Authorizations for dates of service starting on or after March 1, 2023, can be submitted through the Optum Portal beginning February 16, 2023.
- Authorizations for dates of service before March 1, 2023, must continue to be submitted through ProAuth.
- NEW 2023 Product-specific drug authorization request forms are now available. These forms should be completed and submitted with your request along with supporting medical records.
- For a list of preferred drugs please see our Part B Step Therapy Drug List (PDF)
Authorization Instructions
Prior Authorization
- For prescriptions, please visit our Pharmacy page.
- For mental health/substance abuse services for Generations Advantage Plan members call BHCP at 1-800-708-4532.
- For mental health/substance abuse services for US Family Health Plan members call BHCP at 1-888-812-7335.
- Imaging Services for Generation Advantage members ONLY: eviCore manages authorizations for the following advanced imaging services:
- Non Cardiac CT, MRI, PET and Nuclear Medicine services
- Call eviCore at 1-888-693-3211 OR use eviCore’s self-service web portal.
- For both Generations Advantage and US Family Health Plan members, prior authorization may be requested by the member's PCP or by the servicing provider/facility.
- Prior authorization is not required for emergency care.
- Prior authorization requests should be submitted at least 14 calendar days prior to the date of service or facility admission.
- If the servicing provider is not part of the Martin’s Point network, we require a letter of medical necessity (including clinical
documentation) explaining why the service(s) can only be provided by this specialist
USFHP Referral Instructions (active starting 10/1)
As a TRICARE Prime® plan, US Family Health Plan members are required by TRICARE® to receive a referral from their PCP before seeing any other provider or specialist (exceptions include, but not limited to, allowance for self-referral for preventive and emergency care).
Effective October 1, 2023 and pursuant to new TRICARE reporting requirements, the Martin’s Point US Family Health Plan will require that referrals to other providers or specialists be submitted to the health plan. Specialists who are referring to another specialist will be required to submit a referral.
For more information, see the US Family Health Plan referral process FAQs.