INPATIENT SERVICES Commercial Medicare. Notification required only, as soon as possible, but no later than 24 hours

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1 Effective: January 1, 2016 Arizona Prior Authorization Requirements HMO (including CommunityCare HMO) Point-of-Service (POS) PPO Advantage (MA) HMO The following services, procedures or equipment are subject to prior authorization requirements (unless noted as notification required only), as indicated by under the applicable line of business. If is not present, prior authorization may not be required, or the service, procedure or equipment may not be a covered benefit. CPT and ICD codes must be provided. All services are subject to benefit plan coverage limitations, members must be eligible, and medical necessity must exist for any plan benefit to be a covered service irrespective of whether or not prior authorization is required. This prior authorization list contains services that require prior authorization only and is not intended to be a list of covered services. The member s Evidence of Coverage (EOC) or Certificate of Insurance (COI) provides a complete list of covered services. EOCs and COIs are available to members on the member portal at or in hard copy on request. Providers may obtain a copy of a member s EOC or COI by requesting it from the Health Net Provider Services Center. Unless noted differently, all services listed below require prior authorization from Health Net of Arizona, Inc. and Health Net Life Insurance Company (Health Net). Refer to prior authorization contacts on page 5 for submission information. For POS and PPO members living outside of Arizona, prior authorization is provided by First Health. Providers can refer to the member s Health Net identification (ID) card to confirm product type. For reference, the CommunityCare HMO line of business is abbreviated CC. INPATIENT SERVICES Acute rehabilitation Behavioral health or substance abuse Authorized by MHN facility Hospice For, covered under Original Hospital Skilled nursing facility Urgent/emergent admission Notification required only, as soon as possible, but no later than 24 hours or by next business day; contact the Health Net Hospital Notification Unit OUTPATIENT PROCEDURES, SERVICES OR EQUIPMENT Ambulance Non-emergency air or ground transportation Applied behavioral analysis (ABA) and Contact MHN other forms of behavioral health treatment (BHT) for autism and pervasive developmental disorders Requires notification, certification of diagnosis and treatment plan for the first 6 months of treatment; after 6 months, prior authorization is required for determination of ongoing medical necessity Page 1 of 5

2 Arizona HMO (including CommunityCare HMO), POS, PPO, and Products Back surgery Includes laminotomy, diskectomy, vertebroplasty, and nucleoplasty Bariatric procedures Surgical procedure Behavioral health and substance abuse Authorized by MHN Includes neuropsych testing ordered by a psychiatrist Prior authorization not required for office visits Blepharoplasty (includes brow ptosis) Surgical procedure Breast reduction and augmentation Surgical procedure Chiropractic care and acupuncture Prior authorization not required for initial evaluation visits Contact ASH Chondrocyte implants Cochlear implants Clinical trials For, covered under Original Custom orthotics Custom-made items are not covered benefits for commercial plans Dermatology (in-office procedures) Includes: chemical exfoliation, electrolysis ( ) dermabrasion/chemical peel ( ) laser treatment ( ) skin injections and implants ( ) Durable medical equipment (DME) Contact Health Net for bone growth stimulators Contact Preferred Home Care for members within Arizona or First Health for POS/PPO members living outside Arizona for the following: o continuous positive airway pressure (CPAP) o hospital beds Contact Preferred Home Care for the following: o custom-made items o power wheelchairs o scooters Custom-made items, power wheelchairs and scooters are not covered benefits for commercial plans Enhanced external counterpulsation (EECP) Excision, excessive skin and subcutaneous tissue (including lipectomy) of the abdomen, thighs, hips, legs, buttocks, forearms, arms, hands, submental fat pad, and other areas Effective: January 1, 2016 Page 2 of 5

3 Arizona HMO (including CommunityCare HMO), POS, PPO, and Products Experimental/investigational services and new technologies Includes, but is not limited to, those listed in the Investigational Procedures List located on the Health Net provider website at provider.healthnet.com > View our Medical Policies > Investigational Procedure List Genetic testing Laser-assisted UPPP (LAUP) Surgical procedure Liposuction Mastectomy for gynecomastia Surgical procedure Maternity Notification required only at time of first prenatal visit Neuro and spinal cord stimulators Nonpreferred providers Covered at out-of-network benefit level for POS and PPO members Occupational and speech therapy Includes home setting Initial evaluation does not require prior authorization Orthognathic procedures Includes TMJ treatment Surgical procedure Otoplasty Outpatient diagnostic procedures Authorized by evicore healthcare Includes: o cardiac catheterization o computed tomography (CT) o echocardiography* o magnetic resonance angiography o nuclear cardiac imaging procedures* o positron-emission tomography (PET) o sleep studies (MRA) o magnetic resonance imaging (MRI) *Authorization may be approved only when services are rendered at an evicore healthcare registered facility. Includes home setting Outpatient physical therapy Initial evaluation does not require prior authorization Panniculectomy Posterior tibial neuro stimulation/pelvic Surgical procedure floor stimulation Prosthetics Items exceeding $2,500 in billed charges Radiation therapy Authorized by evicore healthcare Rhinoplasty Surgical procedure Septoplasty Surgical procedure Total joint replacements Includes ankle, hip, knee, and shoulder Not covered by in outpatient setting Effective: January 1, 2016 Page 3 of 5

4 Arizona HMO (including CommunityCare HMO), POS, PPO, and Products Transplant-related services Including evaluation Authorized by Health Net Transgender services Treatment of varicose veins Surgical procedure Uvulopalatopharyngoplasty (UPPP) and Surgical procedure laser-assisted UPPP Vermilionectomy (lip shave), with mucosal advancement Vestibuloplasty -STOP OUTPATIENT PHARMACEUTICALS (SUBMITTED UNDER MEDICAL BENEFIT CLAIMS) Hemophilia factors Self-injectables Authorized by HNPS Actemra Aldurazyme Aralast Benlysta Botox Ceredase Cerezyme Cinryze Dysport Fabrazyme Glassia Ilaris Immune globulin Krystexxa Lemtrada Lumizyme Myobloc Myozyme Naglazyme Nplate Orencia Prolastin Provenge Radiesse Remicade Remodulin Rituxan (nononcology only) Sculptra Simponi Aria Soliris Stelara Tysabri Ventavis Vpriv eomin iaflex olair Zemaira Authorized by HNPS Immune globulin examples: intravenous immunoglobulin (IVIG), Hizentra, HYQVIA Effective: January 1, 2016 Page 4 of 5

5 Arizona HMO (including CommunityCare HMO), POS, PPO, and Products OUTPATIENT PHARMACEUTICALS (SUBMITTED UNDER MEDICAL BENEFIT CLAIMS), CONTINUED Aranesp Cosentyx Entyvio Lucentis Makena Mircera Synagis Prior Authorization Contacts Authorized by HNPS Listed below are contact numbers for requesting prior authorization. Also included is contact information for commonly requested Health Net departments and Health Net preferred providers that may receive prior authorization requests. Requests should be submitted to Health Net via fax. The Health Net Request for Prior Authorization form must be completed in its entirety and include sufficient clinical information or notes to support medical necessity for services that are requested. For reference, the CommunityCare HMO line of business is abbreviated CC. CONTACTS Out-of-state POS/PPO Prior authorization request or fax: or Prior authorization request administered by First Health Eligibility verification Health Net Customer Contact Center or for members enrolled in a plan through the Health Insurance Marketplace (HIM) Health Net Pharmaceutical Services (HNPS) ; fax: evicore healthcare Outpatient diagnostic procedures: ; fax: Radiation therapy: (faxed requests not accepted) or MHN (behavioral health provider) Preferred Home Care (preferred provider for DME) or (480) American Specialty Health (ASH) Plans Effective: January 1, 2016 Page 5 of 5