Provider Resources

New Outpatient Therapy Guidelines
Physical and Occupational Therapy Guidelines
Speech Therapy Guidelines
Vision Therapy Guidelines

Prior Approval/Prior Authorization Forms
Prior Approval for Out of State/Out of Network Services
Precertification for Services
Orthodontia Precertification Form
 
Medical Home Program 
Medical Home Selection Form (for members)

Prescription Drug Plan
Current Preferred Drug List 
CVS Caremark Prescription Reimbursement Claim Form
Prior Approval Request for Prescriptions
Prior Approval Request Form for ADD Medications
Prior Approval Request Form for Antipsychotics Medications, and Guidelines

Immunization Resources
CPT Codes for Immunizations
Immunization Schedule for Ages 0-6 years
Immunization Schedule for Ages 7-18 years

Preventative Care
Dental Care Flyer
Vision Care Flyer
Well-Child Exam Flyer
Child Development Flyer
Hearing Screening Flyer

Healthcheck Forms
Healthcheck Provider Manual and Forms
Kindergarten Screening Document

Dental Information
Dental Provider Guide
Dental Procedure Codes (July 2018)

Benefit Resources & Reimbursement
Reimbursement for Developmental Screenings




If there are other forms, or information that would be helpful if listed on this page, please contact us to let us know.