Prior Authorizations

Some services require prior authorization from CountyCare for reimbursement to be issued to the provider.

All out-of-network and out-of-state services require prior authorization except for Emergency Care and Family Planning Services.

Questions? View our FAQs or call the CountyCare Medical Management and Prior Authorization Department at 312-864-8200 / 855-444-1661.

The reports below provide an overview of prior authorization data for the previous calendar year for CountyCare members. This report includes statistical information associated with total number of prior authorization requests received (e.g., approvals, denials, and top five reasons for denial).

Prior Authorization Statistical Data 2022

Prior Authorization Statistical Data 2023

For efficiency and easier tracking, submit your Medical Prior Authorization request through the CountyCare Provider Portal. Click here to login and learn more.

Medical Prior Authorization requests can also be submitted by faxing the Inpatient Prior Authorization Form or Outpatient Prior Authorization Form to:

  • Inpatient Prior Authorization: 1-800-856-9434
  • Outpatient Prior Authorization: 1-866-209-3703
  • For clinical criteria and our Prior Authorization Policies, click here.

For Medical Oncology (adult), Cardiology, Radiology or Radiology Oncology authorization requests:

  • Call: 888-999-7713 (option 1)
  • Fax: 702-726-5186
  • Click here to visit the New Century Provider online portal.

Treatment request forms:

For efficiency and easier tracking, submit your Behavioral Health Prior Authorization request through the CountyCare Provider Portal. Click here to login and learn more.

Behavioral Health Prior Authorization requests can also be submitted by faxing the Behavioral Health Authorization Form to:

  • Behavioral Health Authorization: 1-800-498-8217

CountyCare maintains a Preferred Drug List (PDL), the same PDL as Illinois Medicaid and all Medicaid Health Plans in Illinois. The CountyCare PDL includes a wide variety of generic and brand name drugs. Clinicians are encouraged to prescribe from the CountyCare PDL for their patients who are members of CountyCare.

CountyCare works with CVS Caremark to administer pharmacy benefits, including the pharmacy prior authorization process. CountyCare requires prior authorization for select drugs on the PDL as well as ALL drugs not on the PDL. The PDL indicates which drugs require prior authorization.  Most specialty drugs are not on the PDL and require prior authorization as described below.

Follow these steps for efficient processing of your pharmacy prior authorization requests:

  1. Complete the CVS Caremark: Medication Request Form or Universal PA Form. Include detailed clinical information that will help CVS Caremark understand the need for the drug being requested.
  2. Fax to CVS Caremark at 1-866-255-7569.
  3. Once approved, CVS Caremark notifies the prescriber by fax and member by letter.
  4. For urgent or after-hours requests, a pharmacy can provide up to a 72-hour supply of most medications by calling the CVS Caremark Pharmacy Help Desk at: 1-800-364-6331.
  5. All pharmacy prior authorization requests for CountyCare members should be submitted to CVS Caremark.

Criteria for medication coverage:

To submit a specialty pharmacy prior authorization, complete the Medication Request Form.
Fax all completed forms to CVS Caremark at 1-866-255-7569.

To submit a dental prior authorization, Login Here or call 866-337-1594

To refer to the CountyCare dental benefits, click here.

To submit a vision prior authorization, login here or call 866-337-1596.

To view clinical criteria for prior authorization, click here.