Commercial Criteria

All commercial (non-Medicare) plans have developed criteria that require prior authorization. You can find the latest updates for Florida Blue coverage guidelines by visiting mcgs.bcbsfl.com. The following Capital Health Plan-developed criteria require prior authorization:

• Applied Behavioral Analysis Services
• Colonoscopies
• Long Term Acute Care Hospitalization
• Magnetic Resonance Imaging (MRI) Cervical Spine
• Magnetic Resonance Imaging (MRI) Lumbar Spine
• Residential Eating Disorders Treatment
• Residential Substance Abuse Treatment
• Skilled Nursing Facilities
• Thoracic Outlet Syndrome
• Weight Loss Services
• Wound Treatment Centers

Florida Blue Adopted Criteria

Capital Health Plan has adopted the Florida Blue medical coverage policies as our criteria for Commercial members. Coverage policies that require prior authorization are listed below. To obtain the necessary medical coverage guidelines, please visit mcgs.bcbsfl.com.

This list is not all-inclusive:

• Bio-Engineered Skin and Soft Tissue Substitutes; Amniotic Membrane and Amniotic Fluid
• Cervical Spine Surgery
• Cochlear Implants
• Continuous Glucose Monitoring
• Continuous Passive Motion Device
• Computed Tomographic Colonography (Virtual Colonoscopy or CT Colonoscopy)
• Deep Brain Stimulation
• External Insulin Infusion Pumps and Supplies
• Functional Neuromuscular Stimulation
• Genetic Testing:
  • Analysis of Human DNA as a Technique for Colorectal Cancer Screening
  • Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer
  • Genetic Testing
  • Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2)
  • Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
  • KRAS, NRAS, and BRAF Variant Analysis (Including Liquid Biopsy & MicroRNA Expression Testing) in Metastatic Colorectal Cancer
  • Multigene Expression Assay for Predicting Recurrance in Colon Cancer
  • Tumor/Genetic Markers
  • Bariatric Surgery
  • Blepharoplasty/Brow Surgical Procedures
  • Mastectomy for Gynecomastia
  • Orthognathic Surgery
  • Panniculectomy and Abdominoplasty
  • Prosthetics
  • Reduction Mammoplasty (Breast Reduction)
  • Rhinoplasty

  Prior Authorization

  Effective 1/1/2017, the Florida Legislature amended a statute to require all insurers use the Universal Prior Authorization Form. Therefore, as of 1/1/2017, Capital Health Plan will only accept this form when submitted and completely filled out as directed by the instructions. Incomplete forms will not be considered a valid request for services and therefore will not be processed.

  Capital Health Plan Artboard 1

  We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. You may access the Nondiscrimination and Accessibility Notice here.

  © 2024 Capital Health Plan, An Independent Licensee of the Blue Cross and Blue Shield Association. All rights reserved.

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