CONNECTICARE, INC. & AFFILIATES
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1 CONNECTICARE, INC. & AFFILIATES INSERT PAGE FOR PRE-CERTIFICATION AND PRE- AUTHORIZATION LISTS UPDATE Applies to all ConnectiCare health plans, except the ConnectiCare Network USA-PPO Plan and as otherwise noted in your Membership Agreement, Certificate of Coverage, Membership Agreement and Member Handbook, Policy, self funded Summary Plan Description/Plan Document (SPD) and Prescription Drug Rider. SERVICES REQUIRING PRE-AUTHORIZATION OR PRE-CERTIFICATION Effective January 1, 2011, the list of services, equipment, and supplies requiring Pre-Authorization or Pre-Certification in your Membership Agreement, Certificate Of Coverage, Membership Agreement and Member Handbook, Policy, or self funded Summary Plan Description/Plan Document, as applicable, is hereby deleted and replaced as follows. Services listed as requiring Pre-Authorization or Pre- Certification may or may not be covered under your benefit Plan, if you are enrolled in a self funded Plan. Please refer to the Benefits section of your Summary Plan Description/Plan Document (SPD) to see if the services, equipment and supplies are covered under your self funded Plan. Please note, those services, equipment, and supplies that are new from the previous list, are highlighted in red text. You Need Pre-Authorization Or Pre-Certification For The Following: Admissions: Hospital admissions that are elective or not the result of an Emergency, including: Acute Hospitals admissions* Partial Hospitalizations Programs (PHP)* Rehabilitation Facility admissions* Residential Treatment Facilities* Skilled Nursing Facility admissions Sub-acute care admissions Ambulance/Medical Transportation: Land or air ambulance/medical transport that is not due to an Emergency Durable Medical Equipment (DME) And Prosthetics Pre-Authorization will only be required for the following items: insulin pumps, wound vacs, real time continuous blood glucose monitors, customized wheelchairs and scooters, osteogenic stimulators (including spinal, non-spinal and ultrasound). Prosthetic/artificial limbs, including the purchase, replacement and repair of whole limb or part of limb will also require Pre-Authorization if you are enrolled in one of our ConnectiCare of Massachusetts, Inc. plans. Elective Services & Procedures: Applied Behavioral Analysis (ABA) for the treatment of Autism Spectrum Disorder (ASD) (if a covered benefit)* Artificial Intervertebral Disc Cancer clinical trials Cardiac monitoring with Mobile Cardiac Outpatient Telemetry or continuous computerized daily monitoring with auto-detection (no Pre-Authorization is required for standard Holter monitors or loop event recording devices) Chondrocyte Implantation or Transplantation Corneal Pachymetry, repeat testing only Craniofacial treatment Dental anesthesia/procedures Extended outpatient behavioral health treatment visits beyond minutes in duration with or without medication management* Gastric bypass surgery, including laparoscopic (if a covered benefit) Genetic testing, except for cystic fibrosis, routine chromosomal analysis (e.g., peripheral blood or tissue culture, chorionic villus sampling, amniocentesis), and FISH testing for lymphoma or leukemia Hospital clinics, non-contracted or out of the Service Area Mammoplasty (breast augmentation or reduction) Oncotype DX breast cancer test Oral surgery (if a covered benefit) Reconstructive surgery Septoplasty (surgery of the nose), except when requested by an Ear, Nose and Throat Specialist Sleep apnea surgery or oral appliance treatment for sleep apnea Solid organ transplants (except cornea) and bone marrow transplants (all transplant Pre-Authorizations must be done at least ten business days prior to services being rendered) Stereotactic radiosurgery TMJ surgery (if a covered benefit) Varicose vein surgery Home Health Care: Home health services Home infusion therapy Hospice care Infertility Services Does not require Pre-Authorization, if you are enrolled in one of our ConnectiCare of Massachusetts, Inc. plans Intensive Outpatient Treatment Programs (IOP*) Injectable Drugs & Nutritional Supplements: Nutritional supplements and food products, including modified food products for inherited metabolic diseases and specialized formulas (if a covered benefit) Neuropsychological Testing (behavioral health* and medical purposes) Outpatient Radiological Services (except when such radiological services are done in conjunction with a biopsy or other surgical procedure): Bone mineral density exams ordered more frequently than every 23 months CT scans (all diagnostic exams) MRI/MRA (all examinations) Nuclear cardiology PET scans Radiation Therapy for Cancer Stress echocardiograms Outpatient Rehabilitative Services: Occupational therapy
2 Physical therapy Speech therapy (including specialty Hospitals, acute care Hospitals and providers of rehabilitation services) Outpatient Electro-Convulsive Treatment (ECT)* Outpatient Behavioral Health Treatment Provided in a Member s Home* Outpatient Treatment of Opioid Dependence* Psychological Testing Over 4 Hours* *Pre-Authorization is conducted by OptumHealth Behavioral Solutions Prescription medications (only applies to certain medications) Effective January 1, 2011, the list of drugs, including specialty drugs, requiring Pre-Authorization contained in your Membership Agreement, Certificate Of Coverage, Membership Agreement and Member Handbook, Policy, Summary Plan Description, as applicable, or our Prescription Drug Rider is hereby deleted and replaced as follows. Please note, those drugs that are new from the previous list, are highlighted in red text: You Need Pre-Authorization For The Following Prescription Drugs: Aciphex Actemra Acthar Gel Actos Actoplus Met Acne-Brand Name Oral Agents; Doryx, Dynacin, Adoxa, Myrac, Soladyn, Minocin PAC Actiq Actonel Adcirca Adoxa Affinitor Agrylin Allegra D AlleRx Alpha 1-Proteinase Inhibitors (All) Aldurazyme Alimta Aloxi Altoprev Ambien CR Amerge Amevive Ampyra Amrix Androderm Androgel Antarra Anzemet Aplenzin Apokyn Aralast Arcalyst Aranesp Aricept Arthrotec Arzerra Ascensia Test Strips Astepro Avandia Avandamet Avandaryl Avastin Avidoxy Avodart Avonex Axert Beconase AQ Betaseron Bexxar Blood Clotting Factors (All) Boniva Injection Boniva TabletsBotox Bravelle Brovana Buphenyl Bydureon Byetta Cabergoline (Dostinex) Cambia Campral Cardura XL Celebrex Cerezyme Certriad Cesamet Cetrotide Chantix Cholesterol Lowering Drugs: Altoprev, Crestor, Lescol/XL, Lipitor, Vytorin Ciltyri Cimzia Cinryze Cladribine Clarinex / D Clindagel Clobex CNL Nail kit Clolar Clomid Coartem Contraceptives Compounded Medications Copaxone Coreg CR Crestor Crinone Cymbalta Dacogen Detrol / LA Dexilant (formerly Kapidex) Differin Doryx Dostinex Duetact Dynacin Dysport Edluar Effexor XR Elaprase
3 Elidel Enbrel Enablex Endometrin Eloxatin Erbitux Euflexxa Evoclin Exalgo Exelon Exjade Extavia Extina Fabrazyme Fenoglide Fentanyl citrate oral Fentora Fexmid Fexofenadine-D Fibrocor Fingolimod Flector Patch Flolan Flu Mist Fluoxetine 40mg capsules Follistim AQ Folotyn Food Supplements Fortamet Forteo Fosamax plus D Frova Fuzeon Ganirelix Gastrocrom Gelnique Genotropin Glassia Gleevec Glumetza Gonal-F Growth Hormones (All) HCG (chorionic gonadotropin) Herceptin Hizentra Humatrope Humira Hyalgan Hycamtin Ilaris Implanon Increlex Infergen Injectable Drugs (All): excluding insulin Interferons (All) Infertility Medications (All) Intron-A Iressa Istodax IV Immune Globulin (IVIG) Ixempra Jalyn Jevtana Kalbitor Keppra XR Kineret Klonopin Wafers Kuvan Kytril Lamictal ODT Lamictal XR Lamisil Oral Granules Lansoprazole Levadex Lescol/XL Letairis Lexapro Lipitor Livalo Lotronex Lovaza (formerly Omacor) Lucentis Lumigan Lumizyme Lunesta Luveris Luvox CR Luxiq Lyrica Macugen Marinol Maxalt/Maxalt MLT Menopur Mepron Metozolv Minocin Combo Pack Mirena Mozobil Myobloc Myozyme Myrac Naglazyme Namenda Naproxinod Nasacort AQ Nasarel Neulasta Nexavar Nexium Nimotop Niravam Norditropin Novarel NPlate Noxafil Novoseven Nutropin/AQ Nuvigil Oforta Oleptro Olux Olux E Omnaris
4 Omnitrope One Touch Test Strips Onglyza Onsolis Oracea Oravig Orencia Orfadin Orthovisc Ovidrel Oxandrin Oxytrol Patanase Paxil CR and CR generic Pegasys Peg-Intron Pennsaid Pexeva Ponstel Prevacid Prevacid Naprapac Prialt Pristiq Prolastin Proleukin Prolia Promacta Proscar Protonix Protopic Provenge Provigil Prozac Weekly Qualaquin Qutenza Rapaflo Razadyne Rebetol (ribavirin) Rebetron Rebif Reclast Relistor Relpax Regranex Remicade Remodulin Repronex Retisert Revatio Revlimid Rhinocort AQ RiaStap Ribavirin Rituxan Rybix ODT Ryzolt ER Saizen SancturaSancuso Sarafem Savella Silenor Simponi Smoking Cessation Medications Soladyn Soliris Solzira Somavert Sporanox Sprix Sprycel Steroids, Anabolic Stavzor Stelara Striant Strattera Sucraid Sumavel Dosepro Supartz Sutent Symlin Synagis Synarel Synvisc (hyaluronate sodium) Tasigna Tarceva Temodar Testim Testosterone (All) TevTropin Thalomid Thyrogen Tofranil PM Torisel Toviaz Tracleer Travel Medication: including Malarone, Larium and Aralen Travatan/Travatan Z Treanda Tretin X Treximet Triglide Tykerb Tysabri Tyvaso Uloric Ultram ER Uroxatral Vectibix Velcade Venlafaxine ER Ventavis Verdeso Vesicare Victoza Vidaza Vimovo Vivaglobin Vivitrol Voltaren Gel Votrient Vpriv Vusion Vytorin
5 Weight Loss Medication (if covered by your plan); Meridia, Xenical, Ionamin, Tenuate, etc Welchol Xalatan Xeloda Xenazine Xiaflex Xolair Xyntha Xyrem (Sodium Oxybate) Xyzal Zanaflex Caps Zantac gel dose Zavesca Zegrid Zemaira Zevelin Zolinza Zortress Zyban Zolpimist (Use generic zolpidem first) Zyclara Zyflo CR (Use Singulair first) (*) Pre-Authorization for these prescription drugs is not required within the first 90 days of membership with ConnectiCare. Specialty Drugs: Certain specialty prescription drugs require Pre- Authorization and must be filled through specialty pharmacies. The list of specialty drugs that have this requirement is as follows: Growth Hormone including: Accretropin Genotropin Humatrope Increlex Norditropin Nutropin Nutropin AQ Saizen Serostim TevTropin Blood Clotting Factors including: Benefix Humate P Kogenate FS Monarc M NovoSeven Recombinate Xyntha Hepatitis C Treatments including: Copegus Infergen Peg Intron Pegasys Rebetol Rebetron Ribavirin LHRH Agonists including; Eligard Lupron Trelstar Viadur Vantas Zoladex Multiple Sclerosis Treatments including: Avonex Betaseron Copaxone Extavia Rebif Tysabri Other Drugs including: Acthar Actimmune Apokyn Aralast Botox (botulinium toxin type A) Cerezyme Fabrazyme IVIG (Immuneglobulin) Prolastin Soliris Synagis Thyrogen Xolair Zemaira Oral Oncology Agents Including: Afinitor Gleevec Iressa Nexavar Oforta Revlimid Sprycel Sutent Tarceva Tasigna Temodar Thalomid Torisel Tykerb Votrient Xeloda Zolinza Psoriasis/Rheumatoid Arthritis/Crohn s Disease Treatments including: Actemra Amevive Cimzia Enbrel Humira Orencia Remicade Rituxan RA Simponi Stelara Pulmonary Hypertension Drugs including: Flolan Letairis Remodulin
6 Tracleer Ventavis Infertility Drugs including: Bravelle Chorionic Gonadotropin (HCG) Follistim AQ Ganirelix Gonal-F Menopur Novarel Ovidrel Repronex Viscosupplements including: Euflexxa Hyalgan Orthovisc Supartz Synvisc Synvisc One Except for these changes to the lists of services, equipment, supplies, and drugs that require Pre- Authorization or Pre-Certification as described in your Membership Agreement, Certificate Of Coverage, Membership Agreement and Member Handbook, Policy, or self funded Summary Plan Description/Plan Document (SPD), as applicable, and our Prescription Drug Rider, your Plan, including any other Riders, remains unchanged.
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