Preauthorization Requirements * (as of January 1, 2016)

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1 OFFICE VISITS Primary Care Office Visits Primary Care Home Visits Specialist Office Visits No Specialist Home Visits PREVENTIVE CARE Well Child Visits and Immunizations Adult Annual Physical Examinations Adult Immunizations Routine Gynecological Services/Well Woman Exams Mammography Screenings** Sterilization Procedures for Women Vasectomy Bone Density Testing No Screening for Prostate Cancer Screening for Colon Cancer** All other preventive services with an A or B rating in the current recommendations of the U.S. Preventive Services Task Force and preventive care and screenings for women and children provided for in the Health Resources and Service Administration guidelines. EMERGENCY CARE ** Note that any test considered diagnostic (for example diagnostic mammography or colonoscopy) does not meet the preventive guidelines. Also note that age, frequency and other limits may apply. Emergency Room Services Urgent Care Center Emergency Ambulance Services Non-Emergency Ambulance Services PROFESSIONAL SERVICES AND OUTPATIENT CARE No Advanced Imaging Services (MRI, MRA, CT, CT Angiogram, MEG, EEG, PET) Performed at a Freestanding Radiology Facility or Office Setting Performed as an Outpatient Hospital service * This document is for informational purposes only. Please refer to your Certificate or Policy, or call Customer Service at to confirm that this is the most up to date and complete information. 1

2 PROFESSIONAL SERVICES AND OUTPATIENT CARE (continued) Allergy Testing & Treatment Evaluation and testing (initial visit) Ongoing Treatment Outpatient Surgical Procedures (Ambulatory Surgery Center) Autologous Blood Banking No No No Cardiac & Pulmonary Rehabilitation Performed in a Specialist Office Performed as an Outpatient Hospital service Performed as an Inpatient Hospital service Chemotherapy Performed at a Specialist Office Performed at an Outpatient Infusion Center No Chiropractic Services (initial visit) No Diagnostic Procedures Performed at a Specialist Office No (if procedure includes sedation or anesthesia a prior authorization is required) Dialysis Performed at a Freestanding Center or Specialist Office Setting No Habilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy) Home Health Care (SN, PT, OT, HHA, and ST) No 2

3 PROFESSIONAL SERVICES AND OUTPATIENT CARE (continued) Infertility Services Infusion Therapy Performed at Specialist Office Performed at an Infusion Center Performed as an Outpatient Hospital service Home Infusion Therapy Routine Laboratory Procedures* (all lab services need to go through Core Labs) Performed in a Freestanding Laboratory Facility or Specialist Office No *some genetic tests may require an authorization Obstetrics Global Obstetrics and Gynecology Care (professional services for pre through postnatal care) (a global authorization is entered upon notification of a pregnancy and includes 3 routine sonograms) Inpatient Hospital Services and Birthing Center Home Deliveries Breast Pumps (all types) Interruption of Pregnancy Pain Management Services Pre-admission Testing (includes routine testing) No Pre-authorization Required Radiology Services (routine X-Rays and EKG s) Performed at a Freestanding Center or Specialist Office Setting No (if anesthesia or sedation is used the test requires a prior authorization) Therapeutic Radiology Services Performed in a Freestanding Radiology Facility or Specialist Office Rehabilitation Services (Physical Therapy, Occupational Therapy or Speech Therapy) No 3

4 PROFESSIONAL SERVICES AND OUTPATIENT CARE (continued) Second Opinions No Surgical Services (including Oral Surgery, Reconstructive Breast Surgery, Other Reconstructive & Corrective Surgery, Transplants, & Interruption of Pregnancy) Inpatient Hospital Surgery Outpatient Hospital Surgery Surgery Performed at an Ambulatory Surgical Center(ASC) Office Surgery for office-based surgeries that require general anesthesia, moderate or deep sedation ADDITIONAL SERVICES/THERAPIES-TREATMENTS ABA Treatment for Autism Spectrum Disorder No Acupuncture (not covered for all plans; please refer to your specific benefit plan coverage) Experimental Treatments/Therapies Clinical Trials No Not a Covered Benefit COMMUNICATION DEVICES Augmented Assistive Communication Devices for Autism Spectrum Disorder EQUIPMENT & SUPPLIES Diabetic Equipment, Supplies & Self-Management Education Diabetic Equipment, Supplies and Insulin (30-Day Supply) Insulin Pumps & Supplies Diabetic Shoes Diabetic Education Durable Medical Equipment & Braces No No for up to 12 visits annually; Authorization required for visits 13 and up for Items $500 and Above (all breast pumps require a preauthorization) 4

5 EQUIPMENT & SUPPLIES (continued) External Hearing Aids (all ages) Cochlear Implants (all ages) Hospice Care Inpatient Outpatient Durable Medical Supplies Prosthetic Devices External No INPATIENT ADMISSIONS Inpatient Hospitalization for a Continuous Confinement Observation Stay Skilled Nursing Facility (SNF) Acute Inpatient Rehabilitation Services (notification of admission is required within 1 business day of an admission to an acute care facility) No / Notification Required MENTAL HEALTH & SUBSTANCE ABUSE Inpatient Mental Health Care (continuous confinement) Partial Day Hospitalization & Intensive Outpatient Programs Inpatient Substance Abuse (continuous confinement) Outpatient Mental Health Services Outpatient Substance Abuse Services No (outpatient therapies such as ECT requires a preauthorization) No PRESCRIPTION DRUGS Retail Pharmacy - 30 Day Supply Tier 1 Tier 2 Tier 3 for certain drugs Retail Pharmacy - Up to a 90 Day Supply For Maintenance Drugs Tier 1 Tier 2 Tier 3 for certain drugs 5

6 PRESCRIPTION DRUGS Mail Order Pharmacy - Up to a 90 Day Supply Tier 1 Tier 2 Tier 3 for certain drugs PEDIATRIC DENTAL & VISION CARE Pediatric Dental Care Preventive/Routine Dental Care Major Dental (Endodontics & Prosthodontics) Orthodontia No Pediatric Vision Care Exams Lenses & Frames Contact Lenses No 6

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