2014 Apple Health Benefit Grid

2014 Apple Health Benefit Grid BH+/BH S-Med/S-Chip Requirements Adult Services: Age 19 Children Services: Age 18 Abortion, Spontaneous (miscarriage) Alcohol and Substance Abuse Services, Inpatient, Outpatient, and Detoxification Not required (See Chemical Dependency) Member may self refer to contracted women s health care providers. If provider is not in network then plan approved referral. Yes Yes Clients enrolled in a Medicaid agency contracted-managed care plan may self-refer to providers not contracted with their plan for: Medicaid-approved family planning provider A Medicaid agencycontracted local health department/sti clinic A Medicaid agencycontracted provider who provides abortion services A Medicaid agencycontracted pharmacy (See Chemical Dependency) (See Chemical Dependency) (See Chemical Dependency) Must be provided by Department of Social and Health Services (DSHS) certified agencies. Call 1-877-301-4557 for specific information. Allergy Injections a Physician's order.if Yes Yes by DSHS. Allergy Office Visit physician's order. If provider is not participating then plan approved referral is required Yes. Yes. by DSHS. 2014 CHPW Apple Health Benefit Grid 10/13/2014 3:13:38 PM Page 1

Requirements Adult Services: Age 19 Children Services: Age 18 Allergy Testing/ Serum physician's order. If provider is not participating then plan approved referral is required Yes Yes by DSHS. Alternative Care: Acupuncture Alternative Care: Biofeedback Therapy Not required physician's order. If provider is not participating then plan approved referral is required Yes. Yes. by DSHS CHPW Enhanced benefit. Alternative Care: Chiropractic Treatment Only required when >12 visits are billed for children who are eligible for it to be a covered service. Provider Must Be a Licensed Chiropractor. If provider is participating then a Physician's order. If provider is NOT participating then a Plan Approved Referral Not for member s 21 years of age or older. for children only (age 20 and younger) with referral from PCP after well child screening. To be eligible, clients must be 20 years of age and younger and referred by a screening provider under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. Please refer Chiropractic Services for Children Billing Instructions. See http://www.hca.wa.gov/m edicaid/billing/documents/ guides/chiropractic_service s_bi.pdf Alternative Care: Homeopathy Alternative Care: Hypnotherapy Alternative Care: Massage Therapy 2014 CHPW Apple Health Benefit Grid 10/13/2014 3:13:38 PM Page 2

Requirements Adult Services: Age 19 Children Services: Age 18 Alternative Care: Naturopathic Physicians (Naturopathy) Not required CHPW contracts with Naturopaths for Specialty Care services that fall within the scope of the Naturopath s license, are services covered under Medicaid FFS, and are Prescription Drugs included in the CHPW Formulary. Every service-or treatment normally provided by a Naturopath may not be covered under the CHPW member s plan. Naturopath providers contracted as CHPW specialists may not refer members for other services. The member must go back to their PCP for referral requests. Yes Yes Alternative Care: Osteopathic Manipulative Therapy Not required Provider must be participating, and a physician's order is required. LIMITED benefit: Ten (10) osteopathic manipulations per calendar year are covered by the health plan, only when performed by a plan Doctor of Osteopathy (D.O.). LIMITED benefit: Ten (10) osteopathic manipulations per calendar year are covered by the health plan, only when performed by a plan Doctor of Osteopathy (D.O.). by DSHS. Ambulance: Air No, not covered Yes, covered by DSHS. Air ambulance claims must be submitted to DSHS. Effective date: 05/01/2013. Ambulance: Facility-To- Facility Not required Yes. Must be transportation to a higher level care facility. Not to a hospital providing an equivalent or lower level of care. Yes Yes by DSHS. Ambulance: Ground No requirement (par/non-par) Yes Yes by DSHS. Attention Deficit Disorder (See Mental Health) (See Mental Health) (See Mental Health) (See Mental Health) (See Mental Health) (See Mental Health) 2014 CHPW Apple Health Benefit Grid 10/13/2014 3:13:38 PM Page 3

Requirements Adult Services: Age 19 Children Services: Age 18 Birth Control (See Family Planning) Birth Control (See Family Planning) Birth Control (See Family Planning) Birth Control (See Family Planning) Birth Control (See Family Planning) Birth Control (See Family Planning) Birth Defects And Congenital Anomalies: Surgical Treatment Required Prior Yes, when determined to be by DSHS Birth Defects And Congenital Anomalies: Office Visits physician's order. If provider is not participating then plan approved referral is required Yes Yes by DSHS Blood/Blood Component physician's order. If provider is not participating then plan approved referral is required Yes, Including but not limited to, synthetic factors, plasma expanders, and their administration Yes, Including but not limited to, synthetic factors, plasma expanders, and their administration by DSHS Cardiac Rehabilitation Required Prior Yes, when determined to be medically by DSHS Chemical Dependency (Alcohol and Drug): Inpatient Treatment Yes, contact the Division of Behavioral Health and Recovery (DBHR) at 1-877-301-4557 for additional service Chemical Dependency (Alcohol and Drug): Detoxification See Services Section. No, except in cases when there are medical conditions secondary to chemical dependency treatment that require medical attention in emergent, inpatient or outpatient basis (lacerations, seizure, cirrhosis, dehydration). No except in cases when there are medical conditions secondary to chemical dependency treatment that require medical attention in emergent, inpatient or outpatient basis (lacerations, seizure, cirrhosis, dehydration). Yes, contact the Division of Behavioral Health and Recovery (DBHR) at 1-877-301-4557 for additional service Chemical Dependency (Alcohol and Drug): Outpatient (counseling sessions) Yes, contact the Division of Behavioral Health and Recovery (DBHR) at 1-877-301-4557 for additional service 2014 CHPW Apple Health Benefit Grid 10/13/2014 3:13:38 PM Page 4

Requirements Adult Services: Age 19 Children Services: Age 18 Chemical Dependency (Alcohol and Drug): Partial Hospitalization Chemical Dependency (Alcohol and Drug): Residential Treatment Circumcision: Medical Condition Circumcision: Routine a Physician's order.if Yes Yes Cochlear Implants Required Prior Yes, when determined to be medically Complications from Non- Service a Physician's order.if Yes, excluded for a period of 90 days starting the day after the DOS of the non Service. Yes, excluded for a period of 90 days, starting the day after the DOS of the non-covered Service Contraceptive Devices: Injections Member may self refer to contracted women s health care providers. If provider is not in network then plan approved referral. Yes, Depo Provera and Mirena are covered. Yes, Depo Provera and Mirena are covered. Clients enrolled in a Medicaid agency contracted-managed care plan may self-refer to providers not contracted with their plan for: Medicaid-approved family planning provider: A Medicaid agencycontracted local health department/sti clinic A Medicaid agencycontracted provider who provides abortion services A Medicaid agencycontracted pharmacy 2014 CHPW Apple Health Benefit Grid 10/13/2014 3:13:38 PM Page 5

Requirements Adult Services: Age 19 Children Services: Age 18 Contraceptive Devices: IUD Member may self refer to contracted women s health care providers. If provider is not in network then plan approved referral. Yes, cervical caps, diaphragms and IUD s are covered. Yes, cervical caps, diaphragms and IUD s are covered. Clients enrolled in a Medicaid agency contracted-managed care plan may self-refer to providers not contracted with their plan for: Medicaid-approved family planning provider: A Medicaid agencycontracted local health department/sti clinic A Medicaid agencycontracted provider who provides abortion services A Medicaid agencycontracted pharmacy Contraceptive Devices: Over The Counter Products Prescription Yes, Condoms, gels, foams, and creams Yes, Condoms, gels, foams, and creams by DSHS. Contraceptive Devices: Prescriptions & Implants Prescription Yes, Birth control pills Medroxyprogesterone injection,nuvaring, Ortho Evra Yes, Birth control pills Medroxyprogesterone injection,nuvaring, Ortho Evra Cosmetic Services Court Ordered Services Custodial/Convalescent Care No Not No Not Dental: Accidental Services Not required a physician's order. If then a plan approved referral is required. Yes, when services are not performed by a dentist or oral surgeon Yes, when services are not performed by a dentist or oral surgeon Yes, Dental care provided by dentist and some limited orthodontics. Dental: Anesthesia Yes refer to the Department of Aging and Adult Services 206-341-7750 2014 CHPW Apple Health Benefit Grid 10/13/2014 3:13:38 PM Page 6

Requirements Adult Services: Age 19 Children Services: Age 18 Dental: medically Necessary Services a Physician's order.if Yes, when services are not performed by a dentist or oral surgeon. Yes, when services are not performed by a dentist or oral surgeon Yes, when services are performed by a dentist or oral surgeon. Dental: Routine Services Yes, Limited Routine Dental Services are covered as a Fee-For-Service, refer to DSHS Developmental Disabilities (see neurodevelopment treatment) (see neurodevelop ment Treatment) (see neurodevelopment Treatment) (see neurodevelopment Treatment) (see neurodevelopment Treatment) (see neurodevelopment Treatment) Dialysis (hemodialysis, peritoneal, renal (kidney failure) Required Prior.. DME: Apnea Monitor physician's order. If provider is not participating then plan approved referral is required Yes, limited to three (3) months of rentals Yes, limited to three (3) months of rentals DME: Bra's Post Surgical physician's order. If provider is not participating then plan approved referral is required Yes, 2 bras covered post mastectomy only Yes, 2 bras covered post mastectomy only DME: Breast Pumps Electric Purchase only. Limit of 1 per client per lifetime. Required a physician's order. If then a plan approved referral is required. Yes Yes DME: Breast Pumps Hospital Grade Rental only. If client received a kit during hospitalization, an additional kit will not be covered. Required a physician's order. If then a plan approved referral is required. Yes Yes 2014 CHPW Apple Health Benefit Grid 10/13/2014 3:13:38 PM Page 7

Requirements Adult Services: Age 19 Children Services: Age 18 DME: Breast Pumps Manual Purchase only. Limit of 1 per client per lifetime. physician's order. If provider is not participating then plan approved referral is required Yes Yes DME: C-pap/Bi-Pap 2 month rental, auto- Titration Required Prior Yes, Must be determined medically necessary DME: C-pap/Bi-pap Purchase Required Prior Yes, Must be determined medically DME: Chest Compression Devices Required Prior Yes, Must be Determined Medically Necessary by the Plan DME: Communication Devices Required Prior is Required Yes. Yes. DME: Cough Stimulating Devices Not required a physician's order. If then a plan approved referral is required. Yes, Must be Determined Medically Necessary by the Plan DME: Diabetic Supplies Prescription Yes, these supplies can be obtained with prescription at a participating pharmacy. See Fee-For-Service DSHS for more information Yes, these supplies can be obtained with prescription at a participating pharmacy. See for more information Effective for dates of service on and after August 1, 2009, CHP will pay for blood glucose test strips and lancets as follows: 100 per 3 months if the member is not insulindependent; or 100 per month if the client is insulin dependent 2014 CHPW Apple Health Benefit Grid 10/13/2014 3:13:38 PM Page 8

Requirements Adult Services: Age 19 Children Services: Age 18 DME: Durable Medical Equipment Some DME requires prior authorization, check procedure codes for details. All DME with a purchase price greater than $500.00 allowed amount per line item or greater than $1,000 total allowed amount will require prior a Physician's order. If Yes, when determined medically. Yes, when determined medically. DME: Enteral Therapy Formula Required Prior No. Oral enteral nutrition is not covered for members 21 years of age and older. Yes. Oral enteral nutrition is a covered service for members 20 years of age and younger. DME: Fracture Frames PA for purchase not required. PA for rental required physician's order. If provider is not participating then plan approved referral is required Yes Yes DME: Hospital Bed Required Prior Yes Yes DME: Humidifiers Required Prior Yes Yes DME: Incontinent Supplies (briefs, pull-ups, Liners) physician's order. If provider is not participating then plan approved referral is required Yes, Disposable briefs and pull-up pants (any size) are limited to: 150 per month for an adult 19 years of age and older. Disposable pant liners, shields, guards, pads, and undergarments are limited to 200 per month. Yes, Disposable briefs and pull-up pants (any size) are limited to: 200 per month for a child age 3 to 18 years of age. Disposable pant liners, shields, guards, pads, and undergarments are limited to 200 per month. 2014 CHPW Apple Health Benefit Grid 10/13/2014 3:13:38 PM Page 9

Requirements Adult Services: Age 19 Children Services: Age 18 DME: Insulin Pump Required Prior. DME: Lymphedema Sleeve physician's order. If provider is not participating then plan approved referral is required Yes, covered as part of cancer treatment Yes, covered as part of cancer treatment. DME: Nebulizer physician's order. If provider is not participating then plan approved referral is required Yes, purchase only Yes, purchase only DME: Oseogen (Bone Growth Stimulator) Required Prior Yes, Must be Determined Medically Necessary by the Plan DME: Oxygen & Related Equipment Required Prior Yes, Must be Determined Medically Necessary by the Plan DME: Patient Lifts Not required a physician's order. If then a plan approved referral is required. Yes. Yes. DME: Prenatal Therapy and Supplies a physician's order. If then a plan approved referral is required. Yes, Must be determined medically DME: Prosthetics and Orthotics (i.e, Prostheses, Breast Implants) May require prior Check Procedure Codes for more details. a Physician's order.if Yes Yes 2014 CHPW Apple Health Benefit Grid 10/13/2014 3:13:38 PM Page 10

Requirements Adult Services: Age 19 Children Services: Age 18 DME: Suction Pumps a Physician's order.if Yes Yes DME: TENS Unit ( under Medicare only) No, not covered DME: Trapeze Bars a Physician's order.if Yes Yes DME: Ventilators And Related Equipment Required Prior DME: Wheelchairs, Scooters Required Prior Yes must be determined medically DME: Wound Vac Required Prior Yes, Must be Determined Medically Necessary by the Plan Drugs (see prescriptions, Pharmacy (see prescriptions, Pharmacy) (see prescriptions, Pharmacy) (see prescriptions, Pharmacy) (see prescriptions, Pharmacy) (see prescriptions, Pharmacy) Emergency Room Services No Requirement Yes Yes Enteral Therapy Pump Rental Required Prior (Prior ) Yes, Must be determined medically (Prior ) Experimental / Investigational Services and Drugs Eye Ball Polishing a Physician's order.if Yes Yes 2014 CHPW Apple Health Benefit Grid 10/13/2014 3:13:38 PM Page 11

Requirements Adult Services: Age 19 Children Services: Age 18 Eye Exam: Medical Condition (diagnose and treated) a Physician's order.if Yes Yes Eye Exam: Routine members may self refer to contracted providers If provider is not in network then plan approved referral. Yes, one every twenty-four months (21 and Older) Yes, one every twelve months (20 and Younger) Yes, fabrication services & associated fitting services are covered. Eyeglasses and Fitting Services for clients under age 21. You will need to use an Apple Health feefor-service provider. Refer to DSHS. Family Planning: Contraception (emergency) Prescription Yes, at a Participating pharmacy. Yes, at a participating pharmacy. Family Planning: Home Delivery Member may self refer to contracted women s health care providers. If provider is not in network then plan approved referral. Yes, however parent must fill out the CHP newborn selection form within 60 days of child's birth to ensure eligibility Yes, however parent must fill out the CHP newborn selection form within 60 days of child's birth to ensure eligibility Clients enrolled in a Medicaid agency contracted-managed care plan may self-refer to providers not contracted with their plan for: Medicaid-approved family planning provider: A Medicaid agencycontracted local health department/sti clinic A Medicaid agencycontracted provider who provides abortion services A Medicaid agencycontracted pharmacy Page 12

Requirements Adult Services: Age 19 Children Services: Age 18 Family Planning: Newborn Care Greater than 5 days in the hospital requires a separate Hospital Notification. Less than 5 days is covered under Mom's Notification Yes, However parent must fill out the HP newborn selection form within 60 days of child's birth to ensure eligibility Yes, However parent must fill out the HP newborn selection form within 60 days of child's birth to ensure eligibility Clients enrolled in a Medicaid agency contracted-managed care plan may self-refer to providers not contracted with their plan for: Medicaid-approved family planning provider: A Medicaid agencycontracted local health department/sti clinic A Medicaid agencycontracted provider who provides abortion services A Medicaid agencycontracted pharmacy Family Planning: Office Visits Member may self refer to contracted women s health care providers. If provider is not in network then plan approved referral. Yes. Yes. Clients enrolled in a Medicaid agency contracted-managed care plan may self-refer to providers not contracted with their plan for: Medicaid-approved family planning provider: A Medicaid agencycontracted local health department/sti clinic A Medicaid agencycontracted provider who provides abortion services A Medicaid agencycontracted pharmacy Page 13

Requirements Adult Services: Age 19 Children Services: Age 18 Family Planning: Outpatient (includes observations ) Member may self refer to contracted women s health care providers. If provider is not in network then plan approved referral. Yes Yes Clients enrolled in a Medicaid agency contracted-managed care plan may self-refer to providers not contracted with their plan for: Medicaid-approved family planning provider: A Medicaid agencycontracted local health department/sti clinic A Medicaid agencycontracted provider who provides abortion services A Medicaid agencycontracted pharmacy Family Planning: Sterilization for Women(includes tubal ligation) Members may self refer to contracted providers. If provider is not in network then plan approved referral is required. Yes, must be older than 21 years of age and sign a consent form and wait 30 days after signature. (30 day requirement may be waived in cases of premature delivery or emergency abdominal surgery.) Yes, for member less than 21 years old and those who do not Meet other federal requirements. They must sign a consent form and wait 30 days. Forensic Exam Genetic Counseling and Testing: Non-Prenatal Required Prior Genetic services, including testing, counseling and laboratory services, when medically necessary for diagnosis of a medical condition Genetic services, including testing, counseling and laboratory services, when medically necessary for diagnosis of a medical condition Page 14

Requirements Adult Services: Age 19 Children Services: Age 18 Genetic Counseling and Testing: Prenatal is Not a Benefit No, not covered One initial prenatal genetic counseling service billable for each 30 minutes up to 90 minutes. Face to face encounters only. (Telephonic/email encounters are not covered.) Two follow-up prenatal genetic counseling encounters, billable for each 30 minutes up to 90 minutes per encounter, per pregnancy (within an 11- month period). Habilitative Services For HEX (Expansion/Alternative Benefit Plan Members only) Not required For HEX (Expansion/Alternative Benefit Plan Members only) Two follow-up prenatal genetic counseling encounters, billable for each 30 minutes up to 90 minutes per encounter, per pregnancy (within an 11-month period). Ages 20 and younger, no limits to benefit Health Education And Wellness Programs: Diabetic Education a Physician's order.if Yes, up to six hours of diabetes education/diabetes management per client, per calendar year. Yes, up to six hours of diabetes education/diabetes management per client, per calendar year. Health Education And Wellness Programs: Nutritional Counseling May require prior Check Procedure Codes for more details. a Physician's order.if for clients under age 21 when medically necessary and referred by the provider after an EPSDT screening Health Education And Wellness Programs: Asthma Education a Physician's order.if Yes, covered up to 6 combined (group and/or individual) v visits per calendar year. Yes, covered up to 6 combined(group and/or individual) v visits per calendar year. Page 15

Requirements Adult Services: Age 19 Children Services: Age 18 Hearing Aid Devices Not required a physician's order. If then a plan approved referral is required. for clients under age 20. You will need to use an Apple Health feefor-service provider. for clients under age 21. You will need to use an Apple Health feefor-service provider. Hearing Exams (audiology) a Physician's order.if Yes, examinations to determine hearing loss. Yes, examinations to determine hearing loss. HIV/Aids- Screning You have a choice of going to a Family Planning clinic, the local health department, or going to your PCP for the screening. Yes Yes Yes, if member self refers to the public health departments or family planning clinics Home Health Agency Required Prior. Home Health Care Required Prior Is required Yes must be determined medically. Includes Private duty Nursing per HRSA Guidelines Home Infusion Therapy Required Prior. Yes must be determined medically. Includes Private duty Nursing per HRSA Guidelines (Prior ) Home intrauterine Activity Monitoring (Fetal heart Monitor) Home Phototherapy Hyperbilirubinemia a Physician's order.if Yes Yes Hospice Care Required Prior Yes, when determined to be. Includes private duty nursing per HRSA guidelines.. Includes private duty nursing per HRSA guidelines. Page 16

Requirements Adult Services: Age 19 Children Services: Age 18 Hospital Care: Inpatient Inpatient hospital notification - all admits. Prior authorization for all planned inpatient stays. Yes, prior authorization for all planned inpatient stays. Hospital notification for all inpatient stays. Yes, prior authorization for elective inpatient stays. Hospital notification for all nonelective inpatient stays. Hospital Care: Outpatient Surgery HPV (Human papilloma Virus) Test May require prior Check Procedure Codes for more details. a Physician's order.if a Physician's order.if Yes Yes Yes Yes Hyperbaric Oxygen Pressurization Required Prior Yes must be determined medically Immunizations No requirement when administered by the PCP and /or the Public health department (par-only) Yes Yes Immunizations: Menactra (meningococcal vaccine) a Physician's order.if Yes covered for members age 19 under the following conditions: if member is entering college as a freshman and living in a dorm, if member has functional or anatomic asplenis, if member has terminal complement component deficiencies, if member has HIV/AIDS. Yes covered for members age 11, 12, 15 or 18 under the following conditions: if member is entering college as a freshman and living in a dorm, if member has functional or anatomic asplenis, if member has terminal complement component deficiencies, if member has HIV/AIDS. No member cost sharing for preventive health services. Immunizations: Flu Vaccinations No requirement when administered by the Primary Care Provider and /or the Public health department (Participating Provider Only) Yes, FluMist is covered for ages 2 49 only Yes, FluMist is covered for ages 2 49 only Page 17

Requirements Adult Services: Age 19 Children Services: Age 18 Immunizations: Pediatric Immunizations: Proquad (Measles, Mumps, Rubella) Yes for children only: noncovered for adults Yes, for children only; noncovered for adults Immunizations: Shingles (Herpes Zoster) Only covered for over 60 years of age No requirement Only covered for over 60 years of age No Immunizations: Varicella vaccine (Chicken Pox) Impotence Treatment Incarcerated Care Required Services to Inmates of Correctional Facilities: the Contractor shall provide inpatient hospital services to enrollees who were inmates of correctional facilities, and are admitted to the hospital for an overnight stay. When an enrollee who was an inmate of a correctional facility is admitted to the hospital, the contractor will submit all necessary information to HCA regarding the admission. HCA will determine if the enrollee is eligible for coverage of the hospital stay. If HCA determines that the enrollee is eligible for coverage, the contractor is responsible for the hospital stay and all associated services. Yes, please see comments in the requirement field. Yes, please see comments in the requirement field. Yes, please see comments in the requirement field. Page 18

Requirements Adult Services: Age 19 Children Services: Age 18 Infertility, Impotence and Sexual Dysfunction No, not covered No, including but not limited to testing and treatment of infertility, sterility, artificial insemination, sterilization, reversal and in fertilization. No, including but not limited to testing and treatment of infertility, sterility, artificial insemination, sterilization, reversal and in fertilization. No, including but not limited to testing and treatment of infertility, sterility, artificial insemination, sterilization, reversal and in fertilization. Injections: Adalimumab (Humira ) Required Prior Injections: Alpha-1Proteinase Inhibitor (Aralst Np, Glassia,Prolastin, Zemaira) Injections: Amifostine (Ethyol ) Required Prior Injections: Belimumab (Benlysta ) Required Prior Injections: Bevacizumab (Avastin ) Required Prior Injections: Botulinum toxin (Botox /Myobloc ) Required Prior Injections: Brentuximab (Adcetris ) Required Prior Injections: C1 Esterase Inhibitor (Berinert/Cinryze) Injections: Canakinumab (Ilaris) Injections: Certolizumab (Cimzia ) Required Prior Injections: Denosumab (Prolia or Xgeva ) Required Prior Injections: Docetaxel (Taxotere ) Required Prior Page 19

Requirements Adult Services: Age 19 Children Services: Age 18 Injections: Ecallantide (Kalbitor) Injections: Epoprostenol (Flolan) Required Prior Injections: Erythropoiesis - Stimulating Agents (Darbepoetin, Epoetin) Injections: Etanercept (Enbrel ) Required Prescription + ESI PA (if self administered) Prior authorization (only if member is unable to self-administer) Injections: GnRH Agonists (e.g. Lupron) Injections: Golimumab (Simponi ) Required Prior Injections: Granulocytecolony stimulating factor (G-CSF) (Pegfilgrastim ) Required Prior Injections: Growth Hormone (Somatropin ) Required Prescription + ESI PA (if self administered) Prior authorization (only if member is unable to self-administer) Injections: Hyaluronic Acid Derivatives (e.g. Synvisc, Hyalgan) Injections: Ibandronate (Boniva) Injections: Icatibant Acetate (Firazyr) Injections: Iloprost (Ventavis ) Required Prior Injections: Infliximab (Remicade) Page 20

Requirements Adult Services: Age 19 Children Services: Age 18 Injections: Intravenous Immunoglobulin Required Prior Injections: Ipilimumab (Yervoy) Injections: Natalizumab (Tysabri ) Required Prior Injections: Omalizumab (Xolair ) Required Prior Injections: Palivizumab (Synagis ) Required Prior Injections: Panitumumab (Vectibix) Injections: Peginesatide (Omontys) Injections: Pegloticase (Krystexxa) Injections: Pertuzumab (Perjeta) Injections: Ranibizumab (Lucentis ) Required Prior Injections: Rilonacept (Arcalyst) Injections: Rituximab (Rituxan ) Required Prior.. Injections: Trastuzumab (Herceptin ) Required Prior Injections: Ustekinumab (Stelara) Inpatient (All Planned Admissions) Required Prior authorization (hospital notification required for all admits) Yes, when determined to be Page 21

Requirements Adult Services: Age 19 Children Services: Age 18 Interpreter Services No, except for administrative issues only. Such as handling member complaints and appeals. (see DSHS Column for additional services available) No, except for administrative issues only. Such as handling member complaints and appeals. (see DSHS Column for additional services available) No, except for administrative issues only. Such as handling member complaints and appeals. (see DSHS Column for additional services available) Yes, for medical encounters & DSHS Fair Hearings. Interpreter must be certified w/dshs. IV Therapy: Home Required Prior.. IV Therapy: Outpatient Learning Disabilities May require prior Check Procedure Codes for more details. Prior Yes Yes Lymphedema Treatment May require prior Check Procedure Codes for more details. If prior authorization is not required: If provider is participating then a physician s order.if provider is NOT participating then a plan approved referral. Yes, when determined to be Mammogram: Diagnostic Required Prior Yes Yes Mammogram: Screening Not required Members may self refer to contracted providers. If provider is not in network then plan approved referral is required. Yes Yes Manipulation of Spine & Extremities (see Chiropractic) (see Chiropractic care and osteopathic manipulation) (see Chiropractic care and osteopathic manipulation) (see Chiropractic care and osteopathic manipulation) (see Chiropractic care and osteopathic manipulation) (see Chiropractic care and osteopathic manipulation) Maternity Services: Inpatient Hospital Notification Yes Yes Page 22

Requirements Adult Services: Age 19 Children Services: Age 18 Maternity Services: Outpatient Not required Members may self refer to contracted providers. If provider is not in network then plan approved referral is required. Yes Yes Clients enrolled in a Medicaid agency contracted-managed care plan may self-refer to providers not contracted with their plan for: Medicaid-approved family planning provider: A Medicaid agencycontracted local health department/sti clinic A Medicaid agencycontracted provider who provides abortion services A Medicaid agencycontracted pharmacy Maternity Support Services No, not covered Part of the First Steps Program. Call 1-800-322-2588. Medical Nutrition Therapy Not required a physician s order.if then a plan approved referral is required. Medical Nutrition Therapy is covered for all Medicaid LOB s for ages 20 & younger, when referred by PCP or Pediatrician during an EPSDT exam. Referrals must be for the listed appropriate Conditions in HRSA/HCA billing guidelines to Certified Dieticians. Please see Medical Nutrition Therapy Provider Guide in HRSA/HCA billing guidelines: http://hrsa.dshs.wa.gov/billing/docum ents/guides/medical_nutrition_therap y_bi.pdf Provider Specialties that may be paid for Medical Nutrition Therapy: Advanced Registered Nurse Practitioners (ARNP) Certified Dieticians Durable Medical Equipment (DME) Health Departments Outpatient Hospitals and Physicians Page 23

Requirements Adult Services: Age 19 Children Services: Age 18 Mental Health: Inpatient All mental health services when received from a community mental health agency. In-patient psychiatric care must be authorized by a mental health professional from the local community mental health agency. For more specific information, call 1-800-446-0259. Mental Health: Outpatient Treatment Not required Mental health services are covered when provided by a psychiatrist, a psychologist, a licensed mental health counselor, a licensed clinical social worker, or a licensed marriage and family therapist. These services include: Psychological testing, evaluation, and diagnosis. Mental health treatment. Mental health medication management by your PCP or mental health provider. Yes Yes Yes, covered by DSHS feefor service for those members that meet DSHS Access To Care Standard. Mental health provided by Regional Support Network (RSN), for RSN phone numbers. See: http://www.dshs.wa.gov/d bhr/rsn.shtml Methadone Treatment Yes, by the Division of Behavioural Health and Recovery (DBHR). Call 1-877-301-4557 Neurodevelopment Therapy Not required a physician's order. If then a plan approved referral is required. Yes Yes Covers the service through Apple Health fee-forservice for children when provided in an approved neurodevelopmental center. See http://www.doh.wa.gov/c FH/cshcn/docs/ndclistonw eb.pdf. Page 24

Requirements Adult Services: Age 19 Children Services: Age 18 Neuropsychological Testing (CPT 96116, 96118, 96119) Required Prior authorization Yes Yes Obesity Services Occupational Injuries Gastroplasty covered by DSHS Fee For Service. Office Visit Not required a Physician's order.if Yes Yes Orthoptic Therapy None, Not.. Fee-for-service may cover children. Out Of Area : ER No Requirement (par / non-par) Yes Yes Out of Area : Inpatient Hospital Notification Yes Yes Out of Area : Routine Out of Area : Urgent Care (urgently needed care) No requirement (par/non-par) Yes Yes Outpatient Diagnostic: Services, Procedures, And Tests No Requirement (par / nonpart) Yes Yes Yes, the Division of Behavioral Health and Recovery (DBHR) is responsible for toxicology procedures for DBHR clients who are pregnant or post partum on methadone. Call 1-877-301-4557 Page 25

Requirements Adult Services: Age 19 Children Services: Age 18 Outpatient Diagnostic: Laboratory Services There are no referral requirements for Par/Non-Par providers Yes Yes Yes, the Division of Behavioral Health and Recovery (DBHR) is responsible for toxicology procedures for DBHR clients who are pregnant or post partum on methadone. Call 1-877-301-4557 Outpatient Diagnostic: Therapeutic Radiological Service Mri CAT Scans PET Scans, and X-Ray's May require prior Check Procedure Codes for more details. a Physician's order.if Yes, Pet Scans, Some MRI, MRA,and CT Angiography require a Prior. Yes, Pet Scans, Some MRI, MRA, and CT Angiography require a Prior. Over the counter medications Pain Clinic: Alternative Care Pain Clinic: Treatment (e.g. nerve block, epidural) May require prior authorization, check procedure code for details. a Physician's order.if Yes, when determined to be Pain Clinic: Office Visits a Physician's order.if Yes, when determined to be Page 26

Requirements Adult Services: Age 19 Children Services: Age 18 Pain Clinic: Outpatient Rehabilitation May require prior Check Procedure Codes for more details. If prior authorization is not required: If provider is participating then a Physician's order.if provider is NOT participating then a Plan Approved Referral Yes, when determined to be Pain Management a Physician's order.if Yes Yes Palliative Care Required Prior Yes, covered in conjunction with hospice and must be determined medically. Yes, covered in conjunction with hospice and must be determined medically. Pathology Services No Requirement needed (par/non-par) Physical Exams No Requirement when done by the PCP Yes Yes Yes, the Division of Behavioral Health and Recovery (DBHR) is responsible for toxicology procedures for DBHR clients who are pregnant or post partum on methadone. Call 1-877-301-4557 Yes Yes PKU (Phenylketonuria) Formula PKU (Phenylketonuria) Screening a Physician's order.if Yes Yes Yes, DSHS will reimburse hospitals for newborn screenings for PKU and other metabolic disorders Page 27

Requirements Adult Services: Age 19 Children Services: Age 18 Podiatry (including diabetic foot care) Routine care not covered. See limitations/exclusions for coverage. If provider is participating then a physician's order. If provider is NOT participating then a plan approved referral. Yes Yes Prescriptions, Pharmacy: Inpatient Drugs under Hospital Notification (except inpatient psychiatric care, which is covered by DSHS). Yes Yes Yes, for pharmacy products and prescriptions for selfreferred services from health depts., family planning clinics, RSN s, DBHR programs and dentists. Prescriptions, Pharmacy: Mail Order Prescriptions Prescriptions, Pharmacy: Out of Area Drugs May require prior Check Procedure Codes for more details. Prescription Yes, members can obtain prescriptions when out of the service area and filled at a participating pharmacy. Yes, members can obtain prescriptions when out of the service area and filled at a participating pharmacy. Prescriptions, Pharmacy: Outpatient Drugs May require prior Check Procedure Codes for more details. Prescription Yes, must be purchased at a participating pharmacy. Generic drugs will be dispensed unless the generic equivalent is not available. Protease Inhibitors are not covered by CHP. Yes, must be purchased at a participating pharmacy. Generic drugs will be dispensed unless the generic equivalent is not available. Protease Inhibitors are not covered by CHP. Yes, for Protease Inhibitors. Prescriptions, Pharmacy: Take Home Drugs No, must be obtained with a prescription at a participating pharmacy. No, must be obtained with a prescription at a participating pharmacy. N0, must be obtained with a prescription at a participating pharmacy. Page 28

Requirements Adult Services: Age 19 Children Services: Age 18 Preventive Care No requirement when done by the PCP Yes, including but not limited to immunizations, well child checks, screening colonoscopies, mammograms and bone density testing. Yes, including but not limited to immunizations, well child checks, screening colonoscopies, mammograms and bone density testing. Psychiatric Care, Inpatient and Crisis Services (See Mental Health for more information). Pulmonary Rehabilitation No, not covered All mental health services when received from a community mental health agency. In-patient psychiatric care must be authorized by a mental health professional from the local community mental health agency. For more specific information, call 1-800-446-0259. covered Radiation & Chemotherapy May require prior Check Procedure Codes for more details. a Physician's order.if Yes, some agents require Prior Yes, some agents require PA Radiation & chemotherapy: Injectable And Infused Chemotherapy May require prior Check Procedure Codes for more details. a Physician's order.if Yes, some agents require Prior. Yes, some agents require Prior. Page 29

Requirements Adult Services: Age 19 Children Services: Age 18 Radiation & Chemotherapy: Oral Chemotherapy May require prior Check Procedure Codes for more details. a Physician's order.if Yes, some agents require Prior. Yes, some agents require Prior. Rehabilitation: Inpatient Rehabilitation: Outpatient Occupational Therapy See Services Section. a Physician's order.if For Members 21 Years of Age And Older: Initial evaluation, reevaluation at time of discharge and 24 units (approximately 6 hours) per member per calendar year are covered without Prior.Up to 24 additional units (approximately 6 hours) per member per calendar year are covered with Prior. For Members 20 Years of Age And Younger: More than 12 visits per calendar year will require a prior Rehabilitation: Outpatient Physical Therapy See Services Section a Physician's order.if For Members 21 Years of Age And Older: Initial evaluation, reevaluation at time of discharge and 24 units (approximately 6 hours) per member per calendar year are covered without Prior. Up to 24 additional units (approximately 6 hours) per member per calendar year are covered with Prior. For Members 20 Years of Age And Younger: More than 12 visits per calendar year will require a prior Rehabilitation: Outpatient Speech Therapy See Services Section a Physician's order.if For Members 21 Years of Age And Older: Initial evaluation, reevaluation at time of discharge and 24 units (approximately 6 hours) per member per calendar year are covered without Prior.Up to 24 additional units (approximately 6 hours) per member per calendar year are covered with Prior For Members 20 Years of Age And Younger: More than 12 visits per calendar year will require a prior Page 30

Requirements Adult Services: Age 19 Children Services: Age 18 Respite Care (hospice) (please see hospital Care) Reversal of Sterilization Rotavirus Vaccine (Rotateq ) Saliva Testing School Nurse Services (please see hospital Care) (please see hospital Care) (please see hospital Care) (please see hospital Care) (please see hospital Care) Yes, for Health Options Members by DSHS FFS Only for special education students with individual/family special education plan (IFSP). School bills fee for service. Screening Exams: (preventive) No Requirement (par/non par) Yes Yes Screening Exams: (preventive) Colorectal (colonoscopy) if provider is participating then a Physician's order.if Yes, screening and diagnostic colonoscopies are covered. Yes, screening and diagnostic colonoscopies are covered. Screening, Brief Intervention, Referral and Treatment (SBIRT) Not required SBIRT 1 screening and 4 brief interventions so total of 5 units for these two codes (99408 & 99409) per year Yes, when client is age 18 or older Not covered for members younger than 17 Sexual Reassignment (Surgery, Services and Supplies) Yes, may be covered by DSHS Skilled Nursing Facility Required Prior authorization Yes, when medically necessary and when nursing facility services are not covered by Dept of Aging and Adult Services Administration. NOTE: CHP covers all physician services done at the SNF. Yes, when medically necessary and when nursing facility services are not covered by Dept of Aging and Adult Services administration. NOTE: CHP covers all physician services done at the SNF. Yes, when approved by Dept. of Aging and Adult Services (AAS) 1 800 422 3263. Page 31

Requirements Adult Services: Age 19 Children Services: Age 18 Sleep Study Prior authorization (PA) is not required for the initial sleep study.one sleep study per calendar year is allowed and PA for any sleep study after the initial sleep study a Physician's order.if Yes, covered for obstructive sleep apnea and narcolepsy diagnoses only. Yes, covered for obstructive sleep apnea and narcolepsy diagnoses only. Smoking and Tobacco Cessation: Drugs Smoking and Tobacco Cessation: Nicotine Replacement Prescription Yes Yes Not covered by DSHS. Prescription Yes, some may be covered Yes, some may be covered Smoking and Tobacco Cessation: Services If the provider is participating then a physician's order is required. If the provider is not participating then a plan approved referral Yes, Ages 18 and older are covered through Alere Quit-for-Life smoking cessation program. For questions, please call 1-866-784-8454. Not covered for members younger than 18. Substance Abuse (see Chemical Dependency) (see Chemical Dependency) (see Chemical Dependency) (see Chemical Dependency) (see Chemical Dependency) (see Chemical Dependency) Surgeries: Knee Arthroscopy Required Prior.. Surgeries: Shoulder Arthroscopy Required Prior.. Surgeries: Abortion, Voluntary Page 32

Requirements Adult Services: Age 19 Children Services: Age 18 Surgeries: Ambulatory Surgery (outpatient or same day surgery) May require prior Check Procedure Codes for more details. Prior authorization Yes, however some outpatient surgeries require PA. See specific surgery for additional information. Yes, however some outpatient surgeries require PA. See specific surgery for additionalformation. Surgeries: Bariatric Surgery/ Weight Loss Procedures Not Prior Fee- for - Service only Fee- for -Service only Fee- for -Service only Must be approved by the HCA Apple Health fee-forservice program. for the 3- stage bariatric surgery only when medically necessary. Surgeries: Blepharoplasty (Eyelid Surgery) Required Prior.. Surgeries: Breast Reduction Surgery Required Prior.. Surgeries: Cosmetic or Plastic Surgery. Including tattoo removal, face lifts, ear or body (See Additional Information column) (See Additional Information column) (See Additional Information column) (See Additional Information column) (See Additional Information column) Surgeries: Endovenous Laser, Radiofrequency Ablation (Varicose Vein Surgery) Required Prior Yes, when determined medically. Yes, when determined medically. Surgeries: Eye Surgery (laser) (for a medical condition) May require prior Check Procedure Codes for more details. a Physician's order.if Yes, surgeries for a medical condition such as glaucoma, retinal detachment and cataracts are covered. Yes, surgeries for a medical condition such as glaucoma, retinal detachment and cataracts are covered. Surgeries: Eye Surgery (Lasik )(for vision improvement) Page 33

Requirements Adult Services: Age 19 Children Services: Age 18 Surgeries: Hip Replacement Surgery Required Prior.. Surgeries: Hysterectomy (abdominal, vaginal) Required Prior authorization.. Surgeries: Knee Replacement Surgery Required Prior.. Surgeries: Mammoplasty May require prior Check Procedure Codes for more details. Prior authorization Yes, initial reconstruction mammoplasty is covered regardless of whether the member was covered by CHP at the time of theoriginal mastectomy. ( see extra information for more info.) Yes, initial reconstruction mammoplasty is covered regardless of whether the member was covered by CHP at the time of the original mastectomy. (See extra information for more info) Surgeries: Mastectomy If procedure is performed in an inpatient setting then a Hospital Notification is required. If procedure is outpatient and theprovider is participating then a Physician's order.if procedure is outpatient and the provider is NOT participating then a Plan Approved Referral. Yes Yes Surgeries: Reconstructive, Plastic Surgery and Supplies Required Prior Yes, for the following: Plastic & reconstructive services (including implants after a mastectomy) To correct a physical disorder following an injury or incidental to covered surgery Yes, for the following: Plastic & reconstructive services (including implants after a mastectomy) To correct a physical disorder following an injury or incidental to covered surgery Surgeries: Rhinoplasty and Septoplasty Required Prior authorization.. Surgeries: Sclerotherapy (Varicose Veins) Surgeries: Shoulder Replacement Surgery (Inpatient) Required Prior.. Page 34

Requirements Adult Services: Age 19 Children Services: Age 18 Surgeries: Skin Tag Removal No requirement when service is done by primary care provider. No requirement when service is done by primary care provider. Yes, however covered only when performed by the member s assigned PCP. Yes, however covered only when performed by the member s assigned PCP. Surgeries: Spinal Surgeries: Strabismus a Physician's order.if Yes Yes Surgeries: Tonsillectomy and Adenoidectomy If Provider is Participating then Physician's order is Required. If Provider is Not Participating is Required. Yes Yes Surgeries: UPP (Uvulopalatopharyngoplas ty) Required Prior.. Surgeries: Urethral Suspension Required Prior.. Surgeries: Vasectomy a Physician's order.if Yes, must be more than 21 y/o, sign consent form & wait 30 days after signature. For members 20 and younger. Yes, for members less than 21 years old and those who do not meet other federal requirements. They must sign a consent form & wait 30 days after signature. Temporomandibular Joint (TMJ) & Myofacial Pain Not required a physician's order. If then a plan approved referral is required. Yes, medical treatment only. Dental Services are not covered (See DSHS column for dental services). Some diagnostic tests may require a PA (e.g. MRI TMJ and Surgical Treatment ) Yes, medical treatment only. Dental Services are not covered (See DSHS column for dental services). Some diagnostic tests may require a PA (e.g. MRI TMJ and Surgical Treatment ) Yes, services provided by a dentist or that are billed with American Dental Assoc. codes are paid Fee For Service by DSHS. Page 35

Requirements Adult Services: Age 19 Children Services: Age 18 Transplants: Corneal Transplant Hospital Notification Hospital Notification Yes Yes Transplants: Organ Donation or Tissue Donation (Excludes Corneal) Required Prior Yes, covered by CHP for donor s initial medical expenses relating to harvesting of the organ's as well as the costs of treating complications directly resulting from the procedure's provided the organ recipient is a member of CHP. See additional info Yes, covered by CHP for donor s initial medical expenses relating to harvesting of the organ's as well as the costs of treating complications directly resulting from the procedure's provided the organ recipient is a member of CHP. See addition info for ext Transplants: Organ Donation, Tissue Donation & work-up related to Transplants (Excludes Corneal) Required Prior Yes, transplants for: heart, kidney, liver, bone marrow, lung, heartlung, pancreas, kidney pancreas, cornea & peripheral blood stem cell. Yes, transplants for: heart, kidney, liver, bone marrow, lung, heart lung, pancreas,kidney pancreas, cornea & peripheral blood stem cell. Transplants: Transplant Donor Search Required Prior Yes, covered up to 15 searches per calendar year. Yes, covered up to 15 searches per calendar year. Transportation (from and to office visits) home to office or from PCP to specialist Contact a transportation broker in the respective county using the following resource. http://www.hca.wa.gov/m edicaid/transportation/pag es/phone.aspx Unlisted Codes with Charge > $1,000.00 Required Required Required Required Urgent Care (urgently needed care) There are no referral requirements for Par/Non-Par urgent care providers Yes Yes Vaccinations (see immunizations) No, not covered (except shingles vaccination for over 60 years of age) Page 36

Requirements Adult Services: Age 19 Children Services: Age 18 Vaccinations Shingles Only covered for over 60 years of age No requirement Only covered for over 60 years of age No Vision Services (See Eye Exam) See Eye Exam See Eye Exam See Eye Exam See Eye Exam See Eye Exam Vitamins Prescription Yes, some are covered through the pharmacy benefit. Not covered if over the counter Yes, some are covered through the pharmacy benefit. Not covered if over the counter Vitamins: B12 Injections If Provider is Participating in Network than Physican's Order is Required. If Provider is Not In NetworkPlan Approved Refferal Is Required. Yes Yes Vocational Rehabilitation Wound Care: Outpatient a Physician's order.if Yes, more than 4 specialty visits per provider for each calendar year will require a prior Yes, more than 4 specialty visits per provider for each calendar year will require a prior Page 37