• Group and Individual Products (Regence HSA Healthplan 2.0^SM, Innova^®, Engage^®, Activate^SM, Regence Summit^SM, Regence NowSelect^SM, Basic, Standard and Catastrophic High Risk Pool (HRP), Washington Protection Plus (Asotin & Garfield counties only) and InterM^SM)
  
• Medicare Products (Regence MedAdvantage and Medicare Part D Prescription Drug Plans)
• Federal Employee Program (FEP)
• RegenceRx

Complete this form to facilitate the pre-authorization process for medical, surgical or DME services.

Statement of Medical Necessity for Oncotype DX (PDF)

This form is used to facilitate medical necessity for Oncotype Dx® Breast Cancer Assay. Codes include S3854 and 84999. Fax completed forms to 1 (800) 453-4341