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[Call Atlantis Health Plan Utilization Management 1-800-270-9072 for pre-auth requests. Seven days' notice is required prior to admission and/or services being rendered]

FOR ALL MEMBERS, IN-NETWORK SERVICES ENTAIL THE LOWEST OUT-OF-POCKET EXPENSES. Payment is subject to eligibility, policy limits, and exclusions.

• Ambulance/Ambulette for all non-emergency transportation
• Ambulatory/Outpatient surgery
• Anesthesia for endoscopic procedures
• Arteriography
• Arthrography
• Assistant Surgeon
• Audiology treatment (Audiology diagnostic tests do not require pre-authorization)
• Behavioral Health (all services)
• Cardiac Catheterization
• Cardiac and Pulmonary Rehabilitation
• Cast Room
• Chemotherapy
• Chorionic Sampling
• CT Scan (all)
• D & C (including elective abortions)
• Diagnostic sleep studies (to assess sleep apnea and other sleep disorders)
• Dialysis (all types)
• DME; all rentals and purchases of equipment costing >$500
• Elective in-patient admissions
• GI Services, including all endoscopy except sigmoidoscopy
• Home Health Care
• Hospice services
• Injectable Drugs - See attached list
• In-office Surgery
• Investigational devices, treatments, or procedures
• IV Therapy (performed outside the hospital)
• Labor/Delivery Room
• Lithotripsy
• Home social services
• MRA/MRI
• Nuclear Medicine services
• Observation beds
• Occupational Therapy (if a covered benefit)
• Orthotics/Prosthetics (if a covered benefit)
• Out-of-network facility (pre-authorization mandatory for Health Plan policyholders)
• Out-of-network specialist (pre-authorization mandatory for Health Plan policyholders)
• Outpatient surgery (except minor skin surgery - contact Atlantis Health Plan UM for CPT codes)
• PET Scan
• Physical Therapy (if a covered benefit)
• Psychiatric/Psychological services
• Psychiatric/Psychological treatment
• Radiation Therapy
• Rehabilitation facility
• Respiratory services
• Skilled Nursing (if a covered benefit)
• Sonograms, obstetrical (>two per pregnancy)
• Speech Therapy (if a covered benefit)
• Subacute Care facility
• Therapeutic Radiology
• Transplants
• Treatment/Observation room

For all patients, preferred formulary drugs entail the lowest out-of-pocket expense. Payment is subject to eligibility, policy limits, and exclusions. Drugs may be added to or removed from the list as determined by the Atlantis Health Plan Board.

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