Oregon and Washington Prior Authorization Requirements

1 Effective: January 1, 2018. Oregon and Washington Prior Authorization Requirements health Net health Plan of Oregon , Inc. and health Net Life Insurance Company ( health Net). EPO CommunityCare Point of Service (POS) Medicare Advantage HMO (MA HMO). PPO Medicare Advantage PPO (MA PPO). The following services, procedures and equipment are subject to Prior Authorization Requirements (unless noted as notification required only), as indicated by an X under the applicable line of business. If an X is not present, Prior Authorization may not be required, or the service, procedure or equipment may not be a covered benefit. All services are subject to benefit plan coverage, member eligibility and medical necessity in order for any plan benefit to be a covered service, irrespective of whether Prior Authorization is required. When faxing a request, please attach pertinent medical records, treatment plans, test results, and evidence of conservative treatment to support the medical appropriateness of the request.

2 health Net reserves the right to review utilization patterns retrospectively and to address adverse trends with providers. 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 plan contract or Evidence of Coverage (EOC) provides a complete list of covered services. Plan contracts and EOCs are available to members on the member portal at or in hard copy on request. Providers may obtain a copy of a member's plan contract or EOC by requesting it from the health Net Customer Contact Center. Referrals to participating specialists Providers are not required to obtain Prior Authorization from health Net for referrals to health Net participating specialists. This does not change the requirement that EPO, Triple Option/POS or CommunityCare members must coordinate their care through their primary care physicians (PCPs).

3 For MA PPO plans, Prior Authorization is recommended, but not required, for out-of-network coverage. Unless noted differently, all services listed below require Prior Authorization from health Net. Refer to Prior Authorization Contacts on page 7 for submission information. Providers can refer to the member's health Net identification (ID) card to confirm product type. For reference, CommunityCare is abbreviated CC. Commercial Medicare EPO, POS, PPO, CC MA HMO, MA PPO. INPATIENT SERVICES. Behavioral health or substance abuse Authorized by MHN X X. facility Hospice For MA HMO and MA PPO: covered under Original Medicare; X X. notification required only for Case Management Support Effective January 1, 2018 Page 1 of 7. health Net health Plan of Oregon , Inc. and health Net Life Insurance Company EPO, POS, PPO, CommunityCare, MA HMO, and MA PPO Commercial Medicare EPO, POS, PPO, CC MA HMO, MA PPO.

4 INPATIENT SERVICES, CONTINUED. Hospital Acute inpatient admission, inpatient rehabilitation, Long-Term X X. Acute Care Hospital (LTAC). Skilled nursing facility X X. Urgent/emergent admission Notification required only as soon as possible, but no later X X. than 24 hours or by next business day OUTPATIENT PROCEDURES, SERVICES OR EQUIPMENT. Abortion X. Ambulance Fixed-wing aircraft X. Non emergent Balloon sinuplasty X. Bariatric procedures Surgical procedure X X. Behavioral health and substance abuse Authorized by MHN X X. Includes, but is not limited to, neuropsych testing ordered by a psychiatrist Prior Authorization not required for office visit Blepharoplasty (includes brow ptosis) Surgical procedure X X. Breast reduction and augmentation Surgical procedure X X. Except following mastectomy Includes gynecomastia or macromastia Capsule endoscopy X X. Chiropractic care and acupuncture visits Prior Authorization not required for initial evaluation X X.

5 Contact American Specialty health Plans, Inc. (ASH. Plans) for EPO, POS, PPO (in Oregon only), CommunityCare, MA HMO, and MA PPO. Prior Authorization not required for Washington PPO. Chondrocyte implants X X. Clinical trials For MA HMO and MA PPO, covered under Original Medicare; X X. Notification required only Cochlear implants X X. Dermatology (in-office procedures) Includes any procedure directed at improving appearance, X X. except when required for the prompt (as soon as medically feasible) repair of accidental injury or for the improvement of the functioning of a malformed body member. Including but not limited to the following: chemical exfoliation and electrolysis (17360-17380). dermabrasion/chemical peel (15780-15793). laser treatment (17106-17108). skin injections and implants (11900-11980). Effective January 1, 2018 Page 2 of 7. health Net health Plan of Oregon , Inc.

6 And health Net Life Insurance Company EPO, POS, PPO, CommunityCare, MA HMO, and MA PPO Commercial Medicare EPO, POS, PPO, CC MA HMO, MA PPO. OUTPATIENT PROCEDURES, SERVICES OR EQUIPMENT, CONTINUED. Dermatology (in-office procedures) Includes any procedure directed at improving appearance, X. except when required for the prompt (as soon as medically feasible) repair of accidental injury or for the improvement of the functioning of a malformed body member. Including but not limited to the following: excision of lesion scar revision Diagnostic procedures Authorized by National Imaging Associates, Inc. (NIA) X X. Advanced imaging: Computed tomography (CT)/computed tomography angiography (CTA). Magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA). Positron emission tomography (PET) scan Cardiac imaging: Coronary computed tomography angiography (CCTA).

7 Myocardial perfusion imaging (MPI). Multigated acquisition (Muga) scan Stress echocardiography Transthoracic echocardiography (TTE). Transesophageal echocardiography (TEE). Drug testing Prior Authorization required for all quantitative tests for drugs of X. abuse Durable medical equipment (DME) Includes: X X. bone growth stimulators power wheelchairs custom-made items, scooters including wheelchairs hospital bed/mattresses lift devices, including wound vacuum (negative X. Hoyer pressure) devices oxygen TENS unit infusion pumps DME continuous positive airway Refer members to Apria Healthcare X X. pressure (CPAP), bilevel positive airway pressure (BiPAP) and ventilators Enhanced external counterpulsation X X. (EECP). Effective January 1, 2018 Page 3 of 7. health Net health Plan of Oregon , Inc. and health Net Life Insurance Company EPO, POS, PPO, CommunityCare, MA HMO, and MA PPO Commercial Medicare EPO, POS, PPO, CC MA HMO, MA PPO.

8 OUTPATIENT PROCEDURES, SERVICES OR EQUIPMENT, CONTINUED. Excision, excessive skin and X X. subcutaneous tissue (including lipectomy or panniculectomy) of the abdomen, thighs, hips, legs, buttocks, forearms, arms, hands, submental fat pad, and other areas Experimental/investigational services and Includes, but is not limited to, those listed in the Investigational X X. new technologies Procedures List located on the health Net provider website at > Working with health Net > Clinical >. Medical Policies > Investigational Procedure List Facial osteotomy X. Gender reassignment services X X. (Transgender services). Genetic testing Includes counseling X X. Home health services Includes: X. Home health aide skilled nursing visits home infusion social work visits occupational therapy speech therapy physical therapy Hospice Notification required only; covered under Original Medicare X.

9 Hyperbaric oxygen therapy X. Hysterectomy X. Liposuction X X. Maternity Notification required only at time of first prenatal visit X X. Neuro and spinal cord stimulators X. Observation stay Prior Authorization required if over 48 hours X. Occupational, physical and speech Prior Authorization not required for initial evaluation and X X. therapy modalities done on the same day Orthognathic procedures Includes X X. TMJ treatment Surgical procedure Orthotics Custom made orthotics X. Design, construction, and attachment of artificial limbs or other X. systems Otoplasty X X. Effective January 1, 2018 Page 4 of 7. health Net health Plan of Oregon , Inc. and health Net Life Insurance Company EPO, POS, PPO, CommunityCare, MA HMO, and MA PPO Commercial Medicare EPO, POS, PPO, CC MA HMO, MA PPO. OUTPATIENT PROCEDURES, SERVICES OR EQUIPMENT, CONTINUED. Pain management epidural injections X.

10 Facet injections median branch block radio frequency ablation trigger point sacroiliac joint injection (SI). Penile implant X X. Prosthetics Prior Authorization required for items exceeding $2,500 in X. billed charges Design, construction, and attachment of artificial limbs or X. other systems Reconstructive and plastic surgery X. Referrals to nonparticipating providers Applicable to EPO and MA HMO members only X X. Rhinoplasty Surgical procedure X X. Septoplasty Surgical procedure X X. Spinal surgery Includes, but is not limited to, laminotomy, fusion, X X. diskectomy, vertebroplasty, nucleoplasty, stabilization, and X-Stop Total joint replacements X X. Transplant Transplant evaluations and procedures, including but not X X. limited to evaluation, transplant consult visits, HLA typing, donor search, and transplant procedure. Treatment of varicose veins Surgical procedure X X.