Covered and Noncovered Services
HIRSP will cover medically necessary and appropriate services consistent with the HIRSP policy. Prescription drugs must be obtained at a HIRSP certified network pharmacy. A partial list of covered services follows.
Refer to the policy for a full list of covered services, exclusions, conditions, and limitations.
Pap test and pelvic exam
Skilled nursing care
Yearly physical exam
Prior Approval of Health Care Services
Prior Approval is required for many HIRSP and HIRSP Federal services. Please review the information below carefully before obtaining health care services. Not obtaining a prior authorization for these services WILL result in denied claims or reduced payments.
Note: Prior approval does not apply to the HIRSP Medicare Supplement plan.
The Plan Administrator's prior approval is required in order to receive benefits for charges for covered expenses for certain health care services covered under this policy. Most health care services requiring the Plan Administrator's prior approval are listed below, see your policy for complete listing. You are responsible for assuring that the required prior approval is received before health care services are provided by calling 1-866-841-6572 or faxing the request for prior approval to 1-608-226-4777. Failure to comply with the prior approval requirements, excluding paragraph 8. below, will result in no coverage for such health care services.
To assure that health care services are covered, you must obtain the Plan Administrator’s prior approval before you receive any of the following health care services:
- Surgical services for morbid obesity;
- Reduction mammoplasty and blepharoplasty;
- Transplant services;
- Any durable medical equipment that will be rented for more than three months or with a purchase price greater than $1,500;
- Any prosthetic with a purchase price greater than $1,500;
- Pain management procedures as follows:
- percutaneous intervertebral disc procedures (intradiscal electrothermal therapy (IDET), intradiscal electrothermal annuloplasty (IDEA), percutaneous intradiscal radiofrequency thermocoagulation (PIRFT), nucleoplasty, laser assisted disc decompression (LADD), percutaneous disc decompression, chemonucleolysis;
- radiofrequency neuroablation (neurolysis) of the facet joint nerves;
- facet joint injections and medial branch nerve blocks;
- epidural injections, other than epidural injections provided to the pregnant participant in connection with labor or delivery of a newborn child or due to surgery;
- sacroiliac joint injections; and
- artificial intervertebral disc replacement (lumbar artificial disc replacement (LADR) and intervertebral disc prosthesis).
- The following additional health care services, except when such services are provided in an emergency:
- Spinal surgeries;
- PET scans;
- MRA studies;
- Dental repair related to an injury;
- Inpatient admissions to a hospital or residential treatment program. Approval must be received for non-emergency admissions, at least three business days prior to the confinement. Please see subsection B. for the procedures to obtain admission authorization in order to avoid a penalty;
- Spinal cord stimulators;
- Implantable infusion pain pump;
- Intravenous (IV) therapy/infusion therapy performed in your home when prescribed by a physician. Home IV therapy or home infusion therapy includes, but is not limited to, injections (intra-muscular, subcutaneous, continuous subcutaneous), Total Parenteral Nutrition (TPN), and antibiotic therapy;
- Left venticular assist device (LVAD)
- Preventive (routine) breast MRIs.
- Specialty Drugs
Specialty drugs are prescription drugs that have one or more of the following characteristics, as determined by HIRSP: (a) expensive with high medical cost potential; (b) produced through a biotechnology mechanism/process; (c) administered by injection; (d) association with complex clinical management; (e) requires close patient monitoring; and (f) distributed exclusively through a designated specialty pharmacy. Examples are thos prescription drugs prescribed to treat HIV/AIDS, rheumatoid arthritis, multiple sclerosis or cancer including, but not limited to: Rebif, Copaxone, Avonex, Betaseron, Humira, Enbrel, Kineret, Raptiva, Aranesp, Epogen, Procrit, Pegasys, Peg-Interon, Ribavirin, Infergen, and Intron A. Since this list is incomplete and may change from time to time, you should visit the HIRSP website at www.hirsp.org or contact the PBM by calling 1-800-757-5576 to determine if the drug is a specialty drug that requires prior approval.
Specialty drugs also include, but are not limited to: Orencia, Famraszyme, Aralast, Botox injections, Immune Globulin, Infliximab, Tysabri, Nplate, Adriamycin, Campath, Avastin, Velcade, Erbitux, Taxotere, Vidaza, Camptosar, Gemzar, Lupron, Taxol, Vectibix, Alimta, Rituxan, Hycamtin and Interferon. Since this list is not complete and may change from time to time, you should visit the HIRSP website at www.hirsp.org or contact HIRSP by calling 1-866-841-6572 to determine if a drug is a specialty drug that requires prior approval.
New medical or biomedical technology or new surgical methods or techniques may be experimental. You are strongly encouraged to seek prior approval for these health care services to ensure they are payable under the HIRSP policy.
If you don't obtain the Plan Administrator's prior approval before you receive any health care service listed above, benefits for that health care service will not be payable under this policy.
For more specific information about covered services, refer to the HIRSP policy or contact HIRSP Customer Service.