Commercial Criteria

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:

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.

For coverage policies that contain a Certificate of Medical Necessity (CMN) you may complete the CMN in lieu of submitting records. Please submit these by fax to Capital Health Plan's Care Coordination Department at (850) 383-3310. Do not fax the CMN or records to Florida Blue.

This list is not all-inclusive:

  • Cervical Spine Surgery
  • Cochlear Implants
  • Continuous Glucose Monitoring
  • Continuous Passive Motion Device
  • Computed Tomographic Colonography (Virtual Colonoscopy or CT Colonoscopy)
  • External Insulin Infusion Pumps and Supplies
  • Functional Neuromuscular Stimulation
  • Genetic Testing
  • Genetic Testing for Hereditary Breast or Ovarian Cancer
  • Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
  • Hip Arthroplasty
  • Hyperbaric Oxygen (HBO) Therapy
  • Implantable Hearing Devices
  • Knee Surgery:

    • Autologous Chondrocyte Implantation (ACI)
    • Knee Arthroplasty
    • Knee Arthroscopy and Open, Non-Arthroplasty Knee Repair
    • Manipulation Under Anesthesia
    • Meniscal Allograft Transplantation
  • Kyphoplasty and Vertebroplasty
  • Left Atrial Appendage Closure
  • Lumbar Spine Surgery
  • Negative Pressure Wound Therapy Pump
  • Oncotype DX Testing
  • Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders
  • Osteogenesis Stimulators
  • Power Wheelchairs
  • Quantitative Electroencephalography (QEEG)
  • Reconstructive Surgery and Cosmetic Surgery:

    • Blepharoplasty/Ptosis Repair Surgery
    • Mastectomy for Gynecomastia
    • Orthognathic Surgery
    • Panniculectomy and Abdominoplasty
    • Prosthetics
    • Reduction Mammoplasty (Breast Reduction)
    • Rhinoplasty
    • Surgery for Clinically Severe Obesity (Bariatric Surgery)
  • Respiratory Assist Devices (CPAP, APA, BiPAP)
  • Speech Generating Devices
  • Spinal Cord Stimulation
  • Transcranial Magnetic Stimulation
  • Wearable and Non-Wearable Cardioverter-Defibrillators (WCD)

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.

Download the Uniform Prior Authorization Form