Sanford Health Plan is making changes to prior authorization requirements for skin substitute products for commercial members effective Jan. 1, 2027.

Prior authorization will no longer be required for the skin substitute products listed below when used for covered indications. The Health Plan will provide coverage without prior authorization for up to 10 applications within a 12-week period for any of the listed products, except when used for the treatment of breast cancer-related wounds or burns.When used for the treatment of breast cancer-related wounds or burns, there will be no limit on the number of covered applications.

Prior authorization will be required for requests that exceed 10 applications within a 12-week period for all other diagnoses.

Please note that only the skin substitute products listed below are eligible for coverage. Skin substitutes not included on this list are considered non-covered services.

Reimbursable skin substitutes for Sanford Health Plan commercial products

• Kerecis Omega3 MariGen Shield (A2019)
• Apligraf (Q4101)
• Oasis Wound Matrix (Q4102)
• Oasis Burn Matrix (Q4103)
• Integra Bilayer Matrix Wound Dressing (Q4104)
• Integra Dermal Regeneration Template/Omnigraft (Q4105)
• Dermagraft (Q4106)
• Integra Matrix (Q4108)
• Primatrix (Q4110)
• Integra Flowable Wound Matrix (Q4114)
• AlloDerm (Q4116)
• TheraSkin (Q4121)
• DermACELL (Q4122)
• Oasis Ultra Tri-Layer Wound Matrix (Q4124)
• Grafix Core and GrafixPL Core (Q4132)
• Grafix Prime, GrafixPL Prime, Stravix, and StravixPL (Q4133)
• AmnioExcel, AmnioExcel Plus, and BioDExcel (Q4137)
• EpiFix Injectable (Q4145)
• AmnioBand or Guardian (Q4151)
• Kerecis Omega3 (Q4158)
• Affinity (Q4159)
• AmnioBand Injectable (Q4168)
• EpiFix (Q4186) • EpiCord (Q4187)
• PuraPly AM (Q4196)
• PuraPly XT (Q4197)
• Grafix Plus (Q4304)

Providers are encouraged to verify coverage requirements and submit prior authorization requests when the anticipated treatment plan exceeds the covered application limits.