Referrals and preapproval

Some services or medicines may require prior approval or a referral from your primary care provider (PCP).



For some services, you'll need a referral from your primary care provider (PCP) before getting care.


You may need to get a referral from your PCP before:

  • Meeting with a specialist.
  • Going to a hospital for nonemergency care.


Self-referral services

For most services, you'll go to your PCP or another provider in our plan. But there are some services that we'll pay for, even if you get them from a provider who's not in our plan. These are called self-referral services.


You do not need a referral from your PCP for:

  • Family planning services
  • Pregnancy services
  • Emergency services
  • School-based health center services
  • Adult dental care (age 21 and over)
  • Behavioral health and substance use disorder services
  • Certain providers for children with special healthcare needs


For more information on the referral process, check your member handbook or live chat with a representative.


On-the-go health plan access

The Sydney Health app makes it easy to find a doctor, access your ID card, chat with a live representative, and more.

Download Sydney Health . Opens in new window

Preapprovals for medicines


Some medicines need a preapproval, or an OK, from us before your doctor can prescribe them.


Visit the pharmacy page for more information.