Questions about prior authorization? Here’s what you need ...

1 Questions about prior authorization? Here's what you need to know. p What does prior authorization mean? Your NYC Medicare Advantage Plus Plan will Some types of care require your provider to generally cover care as long as it is medically get an approval from us before you receive necessary and the service is included in your care. This is called prior authorization. Evidence of Coverage and benefits charts. p Why is prior authorization needed? p How do I know if I need prior authorization prior authorization helps ensure you get before I receive care? proper care.

2 It helps us work with your doctor It is the provider's responsibility to ask for to evaluate services for medical necessity prior authorization from Empire BlueCross before you receive treatment or services. BlueShield (Empire). You aren't responsible for asking for it when you see a provider p What is medical necessity? that accepts NYC Medicare Advantage Medical necessity means that the services, Plus. We've provided a list on the pages that supplies, or drugs are needed for the follow of some common services to help you prevention, diagnosis, or treatment of your know when to ask.

3 Medical condition and meet accepted standards of medical practice. We use medical p How long does it take for my prior records and recognized clinical guidelines to authorization request to be approved? establish medical necessity. prior authorization requests are expedited based on the enrollee's health conditions. Urgent and emergency situations are expedited in a similar manner. p How does prior authorization work? } If the claim is determined to not be Providers who accept NYC Medicare medically necessary, we will deny the Advantage Plus are required to ask claim and let you know that you have for prior authorization before providing the right to appeal the decision.

4 The certain types of care, and once approved provider CAN bill you for the treatment. by Empire, the provider will only bill you Whether you see an in-network or out-of-net- for your applicable copay or coinsurance. work provider, if your provider does ask for If your provider doesn't ask for prior prior authorization and it is denied: authorization when required, the claim will be denied. The provider CANNOT bill } You will be notified. If you choose to you for the treatment if they did not get continue with the treatment, you will be prior authorization.

5 Responsible for the cost. Out-of-network providers aren't required to } We will let you know that you have the ask for prior authorization. We encourage right to appeal the decision. you to ask your provider to request it for you The important thing to remember is that you before you get care. Here's why: are not responsible for asking for prior autho- } If the provider doesn't ask for prior rization when you see an in-network provider. authorization, Empire will review the If you see an out-of-network provider, you can claim after you've been treated. ask them to request it for you.

6 } If the claim is determined to be medically necessary, we will process it according to the rules of your plan. below is a general list of services to help you know when prior authorization is required or when to ask your provider to request it. Please note, this is not a complete list and is provided as a guide to help you get the most out of your plan. Detailed prior authorization information is available for your providers. Inpatient admissions } Elective inpatient admissions } Rehabilitation facility admissions } Skilled nursing facility admissions } Long-term acute care (LTAC) care Select outpatient services } Orthotics (performed primarily on ankle, back, } Laminectomies/laminotomies foot, and knee)

7 } Laparoscopies } Elective inpatient surgery } Nerve destructions } All potentially cosmetic surgeries } Nonemergency ground, air, and } Arthroscopies/arthroplasties water transportation } Bariatric/gastric obesity surgery } Occupational therapy } Breast reconstruction } Oncology (Breast), mRNA, } Cervical fusions gene expression profiling } Continuous glucose monitoring (CGM). } Pain management } Coronary artery bypass graft (CABG). } Physical therapy } Defibrillator/pacemaker insertion } Sleep studies and sleep-study-related or replacement equipment and supplies } Genetic testing } Spinal orthoses } Endoscopies } Spinal procedures } Epidermal growth factor } Tonsillectomy/adenoidectomy receptor testing } UPPP surgery (Uvulopalatopharyngoplasty - } Home health removal of excessive soft tissue in the back of the throat to } Hyperbaric oxygen therapy relieve obstruction ).

8 } Intracardiac electrophysiological studies (EPS) } Vascular angioplasty and stents catheter ablation } Vascular embolization and } Knee and hip replacements occlusion services } Knee orthoses } Vascular ultrasound Durable medical equipment (DME) and prosthetics } Automated external defibrillators } Pneumatic compression devices } Bone stimulators } Power wheelchair repairs } Cochlear implants } Power wheelchairs, accessories, } Cough assist (insufflator/exsufflator) and power-operated vehicles (POVs). } High-frequency chest wall oscillator } Prosthetics, orthotics } Insulin and infusion pumps } Sleep-study-related equipment and supplies } Left ventricular assist device } Speech-generating devices } Nonstandard wheelchairs and accessories } Nonstandard beds } Spinal cord stimulators } Oral appliances for obstructive } Tumor treatment field therapy sleep apnea } Ventilators } Patient transfer systems } Wound pump Radiology services Transplants.

9 Human organ } CT scan (including CT angiography) and bone marrow/stem cell } Echocardiograms transplants } MRA scan prior authorization is required for } MRI scan Medicare-covered transplant admissions. } MRS scan } Nuclear cardiac scan Inpatient services: } PET scan } Heart transplant } Radiation (oncology) } Islet cell transplant } Radiation therapy } Kidney transplant } Liver transplant Behavioral health services } Lung or double lung transplant } Day hospital/ partial } Multivisceral transplant hospital admissions } Pancreas transplant } Inpatient admissions } Simultaneous pancreas/kidney transplant } Intensive outpatient therapy } Small bowel transplant } Psychological and } Stem cell/bone marrow neuropsychological testing transplant (with or without } Rehabilitation facility admissions myeloablative therapy).

10 } Transcranial magnetic stimulation (TMS) for depression Outpatient services: } Donor leukocyte infusion } Stem cell/bone marrow transplant (with or without myeloablative therapy). Out-of-network/noncontracted providers are under no obligation to treat NYC Medicare Advantage Plus Plan members, except in emergency situations. Please call our Member Services number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services. The NYC Medicare Advantage Plus Plan is offered through an alliance between Empire BlueCross BlueShield Retiree Solutions and EmblemHealth.