REQUEST FOR PRIOR AUTHORIZATION

1 Please check health PlanOAetnaOCignaOAetna Golden medicare PlanOHealth NetOBlue Shield 65 PlusOHealth Net Seniority PlusOBlue Shield Access PlusOPacifiCareOCalifornia CareOSecure HorizonsOO Nutrition Consult for Chronic Disease (CMC)OOOOOOOOOOOOOO Breastfeeding Medicine ReferralOOOP atient Name: LastFirstMIDate of Birth(Mo/Day/Yr) #Gender: MFOther Insurance?Name of Carrier?Job RelatedMVAA ccidentPregnancy Related?YesNoYesNoYesNoYesNoYesNoTax ID#TelephoneFaxName of PCPDateAddressFaxNoAnesthesiologist Required? :YesNoName:Name:Tentative Date of Service/Admission:ICD-9 Codes(required)Diagnosis Description:Date of Onset/InjuryCPT/HCPC Codes(required)# of Days/Visits:Comments:EFFECTIVE 4/01/2009: Within 5 days before the actual date of service, provider MUST confirm that the member's health plan coverage is still in the exception of urgent requests, it is recommended that you do not schedule appointments PRIOR to AUTHORIZATION approval.

2 Emergency services do not require PRIOR AUTHORIZATION and are reviewed retrospectively for message is intended only for the use of the individual/entity to which it is addressed and may contain confidentialinformation. If the reader of this message is not the intended recipient, you are hereby notified that any distribution is RentalDME Purchase over $200 Cosmetic/Reconstructive SurgeryM2A Video Capsule EndoscopySERVICES REQUIRING PRIOR AUTHORIZATION (please check requested service)Colonoscopy; Upper GI Endoscopy REQUEST FOR PRIOR AUTHORIZATIONMRI, MRA, CT & Pet Scans FAX (559) 224-2405 Sleep StudiesProgramsObesity - Referral to General SurgeonObesity SurgeryOut-of- plan ProviderPlastic Surgery ReferralTYPE OF REQUESTPATIENT INFORMATION Phone (559)228-5400 (800) 652-2900 URGENT for acute conditions requiring care within 72 hours or for routine, elective services(See reverse side of this form for more information)Infusions - Ambulatory (See reverse side of this form)Transplants in conjunction with health plan Home health Home.

3 Self-injectables; In-office injectablesFROM - REQUESTING PHYSICIANR equesting Physician (Please Print)Contact Person in Requesting Provider's OfficeAsst Surgeon Required? YesToday's Date:Signature of Requesting PhysicianWhere will services be rendered? (provide name of facility, if other than provider office or patient's home)TO - WHERE WILL PATIENT RECEIVE SERVICES?Physician/Provider/Facility RequestedTelephoneCLINICAL INFORMATIOND escribe Service Requested:1 2 31 2 3 4 Anti-infective Agents Enzyme Therapy Agents Monoclonal AntibodyAloxi Aldurazyme AmeviveCancidas Aralast AvastinFuzeon Ceredase CampathRocephin for Lyme Disease Only Cerezyme

4 ErbituxFabrazymeHerceptinAntihemophilic Agents Naglazyme LucentisBebulin VH Prolastin MacugenFactor VIII Zemaira MylotargFactor IX RaptivaHumate-P Anticoagulant Agents RituxanNovoseven Arixtra SynagisProplex T Fragmin TysabriRecombinant Factor VIII Innohep XolairRecombinant Factor IX Lovenox Peptide AgentsAntineoplastic Agents Growth Hormone Agents ByettaAbraxane Genotropin ForteoAlimta Humatrope NatrecorArranon

5 Increlex SandostatinClolar Saizen Sandostatin LAR DepoEloxatin Somavert Faslodex ViscosupplementationNovantrone Immune Globulins EuflexxaProleukin CytoGam HyalganVelcade IVIG OrthoviscVidaza Vivaglobulin Supartz SynviscBisphosphanate Agents Interferons Boniva Actimmune Miscellaneous AgentsZometa Alferon-N Botox

6 Avonex CopaxoneColony Stimulating Factors Betaseron FlolanAranesp Infergen MyoblocEpogen Intron-A RemodulinLeukine Pegasys VentavisNeulasta PEG-Intron Neumega Rebetron Neupogen Rebif Procrit Roferon-A Anti-Rheumatic Drugs Enbrel Humira Kineret

7 Orencia RemicadeExclusions (does not require PRIOR AUTHORIZATION ): * Re Self-Injectables: *Insulin *Blue Shield Pharmacy Benefit With the exception of the exclusions listed above, self-injectables, infusions and high dollar injectables require PRIOR AUTHORIZATION . This list may not contain every item requiring PRIOR AUTHORIZATION . Please check with Sant UM staff if you are ordering/administering an infusion, self-injectable or high dollar injectable that is not listed here. Self-Injectables, In-Office Injectables, InfusionsPrior AUTHORIZATION List