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Procedure Code

Procedure Description

C9050

EMAPALUMAB-LZSG

J0129

ABATACEPT INJECTION

J0178

AFLIBERCEPT INJECTION

J0584

BUROSUMAB-TWZA 1M

J0585

ONABOTULINUMTOXINA

J0604

CINACALCET, ESRD ON DIALYSIS

J0717

CERTOLIZUMAB PEGOL INJ 1MG

J0800

CORTICOTROPIN INJECTION

J0897

DENOSUMAB INJECTION

J1300

ECULIZUMAB INJECTION

J1428

ETEPLIRSEN, 10 MG

J1459

IVIG PRIVIGEN 500 MG

J1555

CUVITRU, 100 MG

J1556

IMM GLOB BIVIGAM, 500MG

J1557

GAMMAPLEX INJECTION

J1559

HIZENTRA INJECTION

J1561

GAMUNEX-C/GAMMAKED

J1566

IMMUNE GLOBULIN, POWDER

J1568

OCTAGAM INJECTION

J1569

GAMMAGARD LIQUID INJECTION

J1572

FLEBOGAMMA INJECTION

J1575

HYQVIA 100MG IMMUNEGLOBULIN

J1599

IVIG NON-LYOPHILIZED, NOS

J1602

GOLIMUMAB FOR IV USE 1MG

J1745

INFLIXIMAB (REMICADE)

J1930

LANREOTIDE INJECTION

J2323

NATALIZUMAB INJECTION

J2350

OCRELIZUMAB, 1 MG

J2353

OCTREOTIDE INJECTION, DEPOT

J2357

OMALIZUMAB INJECTION

J2503

PEGAPTANIB SODIUM INJECTION

J2778

RANIBIZUMAB INJECTION

J3262

TOCILIZUMAB, 1 MG

J3304

TRIAMCINOLONE ACE XR 1MG

J3357

USTEKINUMAB SUB CU 1 MG

J3380

VEDOLIZUMAB

J3396

VERTEPORFIN INJECTION

J7189

FACTOR VIIA

J7318

DUROLANE 1 MG

J7320

GENVISC 850, 1MG

J7321

HYALGAN SUPARTZ VISCO-3 DOSE

J7322

HYMOVIS INJECTION 1 MG

J7323

EUFLEXXA INJ PER DOSE

J7324

ORTHOVISC INJ PER DOSE

J7325

SYNVISC OR SYNVISC-ONE

J7326

GEL-ONE

J7327

MONOVISC INJ PER DOSE

J7328

GELSYN-3 INJECTION 0.1 MG

J7329

TRIVISC 1 MG

J9022

ATEZOLIZUMAB,10 MG

J9145

INJECTION DARATUMUMAB 10 MG

J9173

DURVALUMAB, 10 MG

J9176

ELOTUZUMAB, 1MG

J9308

RAMUCIRUMAB

J9311

RITUXIMAB, HYALURONIDASE

J9355

TRASTUZUMAB INJECTION

Q2043

SIPULEUCEL-T AUTO CD54+

Q5103

INFLIXIMAB (INFLECTRA)

Q5104

INFLIXIMAB (RENFLEXIS)

  • Prior Authorization Form (PDF)
    You cannot use this form for Medicare non-covered drugs. Non-covered drugs include but are not limited to fertility drugs, drugs given for weight loss, weight gain or hair growth, over-the-counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations).

Your current plan may have an over-the-counter (OTC) benefit that lets you buy OTC health and wellness products. This catalog includes a list of OTC items that you can order to be mailed to your home. Check the catalog for item limits.

Ordering is easy. Just follow the steps in your plan's catalog.

  • 2020 Over-the-Counter (OTC) Catalog – English (PDF) - coming soon
  • 2020 Over-the-Counter (OTC) Catalog – Spanish (PDF) - coming soon

You can help Superior HealthPlan with the way our health plan works. We have a Member Advisory Group that gives members like you a chance to share your thoughts and ideas with Superior. The group meets at least one time every three months. This gives you a chance to talk about your concerns with a variety of people. You also have a chance to tell us how we are doing. You may ask questions or share any concerns that you have about the delivery of services.

In addition, Superior will provide you with refreshments and a gift card as a token of our appreciation for attending! Call Member Services at 1-866-894-1844 (TTY: 711) for information about upcoming Member Advisory Group meetings. Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day.

Planning Your Living Will

An advance directive (such as a living will) is a way to make sure that your medical decisions are known. It is an unpleasant thought, but what if you became too sick to tell the doctor what you want your care to be? Creating a living will allows you to communicate your wishes and make medical decisions in advance of care.

You can also name someone, known as a Medical (health care) Power of Attorney, to make those choices if you cannot.

Creating Your Living Will

Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) recommends all of our plan members take the time to create a living will, designate a Medical Power of Attorney and provide their advance directive to their primary care physician.

To learn more about creating your advance directive, please visit the Medicare website. You can find advance directive forms on the Texas Health and Human Services website.

Once you have completed your advance directive, ask your doctor to put the form in your file. You can also talk to your doctor about the decision making process of creating your living will or advance directive. Together, you can make decisions that will set your mind at ease.

If you should ever need or want to, you can change your advance directive at any time. You should make sure others know you have an advance directive. If you choose to designate a Medical Power of Attorney, that person should be made aware of your advance directive or living will as well.

With an advance directive, you can be sure that you are cared for as you wish, at a time when you cannot give the information. If you have signed an advance directive, and you believe that a doctor or hospital did not follow the instructions in it, you may file a complaint with the Texas Department of Health. If your directive is not being followed, you can call the state’s complaint line at 1-800-252-8263 (TTY: 711).

For more information on an advance directive, please refer to Chapter 8 of your Member Handbook or call Member Services.  We are here to help!

Below is a glossary of terms and definitions for members to reference.

  • Appeal - A request for your managed care organization to review a denial or a grievance again.
  • Complaint - A grievance that you communicate to your health insurer or plan.
  • Copayment - A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.
  • Durable Medical Equipment (DME) - Equipment ordered by a health care provider for everyday or extended use. Coverage for DME may include but is not limited to: oxygen equipment, wheelchairs, crutches, or diabetic supplies.
  • Emergency Medical Condition - An illness, injury, symptom, or condition so serious that a reasonable person would seek care right away to avoid harm.
  • Emergency Medical Transportation - Ground or air ambulance services for an emergency medical condition.
  • Emergency Room Care - Emergency services you get in an emergency room.
  • Emergency Services - Evaluation of an emergency medical condition and treatment to keep the condition from getting worse.
  • Excluded Services - Health care services that your health insurance or plan doesn’t pay for or cover.
  • Grievance - A complaint to your health insurer or plan.
  • Habilitation Services and Devices - Health care services such as physical or occupational therapy that help a person keep, learn, or improve skills and functioning for daily living.
  • Health Insurance - A contract that requires your health insurer to pay your covered health care costs in exchange for a premium.
  • Home Health Care - Health care services a person receives in a home.
  • Hospice Services - Services to provide comfort and support for persons in the last stages of a terminal illness and their families.
  • Hospitalization - Care in a hospital that requires admission as an inpatient and usually requires an overnight stay.
  • Hospital Outpatient Care - Care in a hospital that usually doesn’t require an overnight stay.
  • Medically Necessary - Health care services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.
  • Network - The facilities, providers, and suppliers your health insurer or plan has contracted with to provide health care services.
  • Non-participating Provider - A provider who doesn’t have a contract with your health insurer or plan to provide covered services to you. It may be more difficult to obtain authorization from your health insurer or plan to obtain services from a non-participating provider instead of a participating provider. In limited cases, such as when there are no other providers, your health insurer can contract to pay a non-participating provider.
  • Participating Provider - A Provider who has a contract with your health insurer or plan to provide covered services to you.
  • Physician Services - Health-care services a licensed medical physician (M.D. - Medical Doctor or D.O. - Doctor of Osteopathic Medicine) provides or coordinates.
  • Plan - A benefit, like Medicaid, which provides and pays for your health-care services.
  • Pre-authorization - A decision by your health insurer or plan that a health-care service, treatment plan, prescription drug, or durable medical equipment that you or your provider has requested, is medically necessary. This decision or approval, sometimes called prior authorization, prior approval, or pre-certification, must be obtained prior to receiving the requested service. Pre-authorization isn’t a promise your health insurance or plan will cover the cost.
  • Premium - The amount that must be paid for your health insurance or plan.
  • Prescription Drug Coverage - Health insurance or plan that helps pay for prescription drugs and medications.
  • Prescription Drugs - Drugs and medications that by law require a prescription.
  • Primary Care Physician - A physician (M.D. - Medical Doctor or D.O. - Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health-care services for a patient.
  • Primary Care Provider - A physician (M.D. - Medical Doctor or D.O. - Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist, or physician assistant, as allowed under state law, who provides, coordinates, or helps a patient access a range of health-care services.
  • Provider - A physician (M.D. - Medical Doctor or D.O. - Doctor of Osteopathic Medicine), health-care professional, or health-care facility licensed, certified, or accredited as required by state law.
  • Rehabilitation Services and Devices - Health-care services such as physical or occupational therapy that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled.
  • Skilled Nursing Care - Services from licensed nurses in your own home or in a nursing home.
  • Specialist - A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions.
  • Urgent Care - Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.

Take Charge of Your Mental Health

We all have our struggles.

Finding support to focus on your emotional health is important.

Now you can use web and mobile tools to help you get better and stay mentally strong.

myStrength is a free online tool to help you live your best life. myStrength is available 24/7 from your computer or mobile device. It offers personalized resources to improve your mood. Learning to use myStrength’s tools can help you overcome the challenges you face.

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  • Hundreds of wellness resources
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Your privacy is our top priority. myStrength is a confidential and safe place for you.

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  1. Visit the myStrength website.
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