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Health Tradition Health Plan requires prior authorization and approval for covered services by the plan before services are received by a member from an out-of-network provider. Mayo Clinic is considered an out-of-network provider.

We use the External Referral/Prior Authorization form for these requests, except for those specialized services of Bariatric Surgery and Mammoplasty below.

Please complete the appropriate form and submit it via confidential fax to 608-781-9654 or mail to Health Tradition Health Plan, PO Box 188, La Crosse, WI 54602-0188.

Medical

• External Referral Request - for La Crosse, Onalaska, and Holmen Clinics Only.
• External Referral/Prior Authorization Request - All other Franciscan Skemp Locations
• External Referral/Prior Authorization Request - Luther Midelfort
• DME Request Form
• Prior Authorization Request for Bariatric Surgery Evaluation
• Prior Authorization for Kyphoplasty Procedure
• Prior Authorization Request for Breast Reduction Surgery (Mammoplasty) Evaluation

Drugs/Pharmacy

• Health Tradition Drug Prior Approval
  (This form is to be used for drugs administered in the office setting only. Drugs administered in the office are reviewed by Health Tradition Health Plan.)
• Prior Authorization - Weight Loss Medication
• Prior Authorization Drug Request
• Prior Authorization - Lansoprazole (Prevacid solutabs)
• Prior Authorization - Memantine (Namenda)
• Prior Authorization - Celecoxib (Celebrex)

Mental Health/Chemical Dependency

• Initial Authorization Request for Mental Health/Chemical
  Dependency Services
• Prior Authorization Request for Continuation of Mental Health/Chemical Dependency Services
• Prior Authorization for Psychological Testing
• Notification for Authorization for MMPI Testing.pdf

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