Scott & White Health Plan

Referrals and Prior Authorizations Under the Medical Plan

To receive the maximum benefit from your Scott & White Health Plan (SWHP) medical plan, you will need to use SWHP-approved doctors, hospitals, pharmacies, and other providers of medical services that are covered by your plan. In the event of an emergency, it is important that you go to the nearest hospital that can provide the best care for your needs. In this case, you may use doctors or hospitals outside the SWHP network.

When you need non-emergency medical services you always have the choice of using out-of-network providers. However, you will not receive the benefits of your SWHP medical plan, and you will be responsible for the full cost of any medical services you receive.   

Most services you need are available through the Scott & White Healthcare system. Some services may require your provider to ask SWHP for prior authorization. If you want to be sure SWHP will pay for this service, you will need prior authorization before these procedures are performed. When authorization is given, SWHP will provide coverage for these services based on the terms of your specific plan.

While this list is subject to change, some services, procedures, or tests that may require prior authorization by SWHP include, but may not be limited to the following:

• Any out-of-network services
• Plastic surgery
• Behavioral Health Services
• Chemical Dependency Services
• Psychiatric testing
• Dental/oral surgery
• Laparoscopy (if for infertility services)
• Laser ophthalmologic treatment, except for retinal disease
• Cardiac/pulmonary rehabilitation
• Coronary CT angiography
• Physical Therapy (PT)/Occupational Therapy (OT)/Speech Therapy (ST) in intermediate and/or long-term care facilities
• Sleep study
• Physical Medicine and Rehabilitation
• Home Care Services: Physical Therapy (PT)/Occupational Therapy (OT)/Respiratory Therapy (RT)/Speech Therapy (ST); social services; aides
• Skilled nursing services
• Organ transplant
• Home Infusion Therapy
• Certain medications noted on formulary
• Specialty pharmacy services
• Spine surgeries
• Major joint replacements
• Long-term Acute Care (LTACH)

If you have  questions about referrals or prior authorizations, please contact our Customer Advocacy Team at (800) 321-7947 or submit your request for assistance online.