REQUEST FOR PRIOR AUTHORIZATION

1 OAetnaOCignaOSecure HorizonsOAetna Golden medicare PlanOHealth NetOBlue Shield 65 PlusOHealth Net Seniority PlusOBlue Shield Access PlusOHumana medicare AdvantageOCalifornia CareOPacifiCareO Breastfeeding Medicine ReferralOOOOO Nutrition Consult for Chronic Disease (CMC)OOOOOOOOOOOOOO NON-URGENT for routine, elective servicePatient Name: LastFirstMIDate of Birth(Mo/Day/Yr) #Gender: MFOther Insurance? Name of Carrier?Job RelatedMVAA ccidentPregnancy Related?YesNoYesNoYesNoYesNoYesTax ID#TelephoneFaxName of PCPDateAddressFaxNoAnesthesiologist Required? : Yes NoName:Name:Tentative Date of Service/Admission:ICD-9 Codes(required)Diagnosis Description:Date of Onset/InjuryCPT/HCPC Codes(required)# of Days/Visits: REQUEST FOR PRIOR AUTHORIZATION Phone (559)228-5400 (800) 652-2900 Please check Health PlanMRI, MRA, CT & Pet ScansM2A Video Capsule EndoscopyColonoscopy; Upper GI Endoscopy FAX (559) 224-2405 SERVICES REQUIRING PRIOR AUTHORIZATION (please check requested service)Obesity - Referral to General SurgeonObesity SurgeryOut-of- plan ProviderDME RentalDME Purchase over $200 Sleep StudiesSignature of Requesting PhysicianPlastic Surgery ReferralHome Health Home SurgeryEndocrinologist Visit (Type II Diabetes)(See reverse side of this form for more information)Infusions - Ambulatory (See reverse side of this form)Injections: Self-injectables.

2 In-office injectablesRequesting Physician (Please Print)Contact Person in Requesting Provider's OfficeTransplants in conjunction with Health plan ProgramsDescribe Service Requested:1 2 3 4 individual/entity to which it is addressed and may contain confidential information. If the reader of this message is not thei ntended recipient, you are hereby notified that any distribution is strictly OF REQUESTW ithin 5 days before the actual date of service, provider MUST confirm that the member's health plan coverage is still in effect. With theexception of urgent requests, it is recommended that you do not schedule appointments PRIOR to AUTHORIZATION approval. Emergencyservices do not require PRIOR AUTHORIZATION and are reviewed retrospectively for message is intended only for the use of theURGENT for acute conditions requiring care within 72 hours or 2 3 Asst Surgeon Required?

3 YesToday's Date:Where will services be rendered? (provide name of facility, if other than provider office or patient's home)Physician/Provider/Facility RequestedComments:PATIENT INFORMATIONFROM - REQUESTING PHYSICIANTO - WHERE WILL PATIENT RECEIVE SERVICES?CLINICAL INFORMATIONT elephoneEFFECTIVE 01/01/2010 Anti-infective Agents Enzyme Therapy AgentsMonoclonal AntibodyAloxi Aldurazyme Aralast Fuzeon Ceredase Cerezyme FabrazymeAntihemophilic Agents Naglazyme Prolastin Zemaira Arixtra Fragmin Innohep Lovenox Peptide AgentsAntineoplastic Agents Growth Hormone Agents Genotropin Humatrope Increlex Saizen Somavert Viscosupplementation CytoGam IVIG Vivaglobulin Actimmune Miscellaneous Agents Alferon-N Avonex Betaseron Infergen Intron-A Pegasys PEG-Intron Rebetron Rebif Roferon-A Enbrel Humira Kineret OrenciaRemicadeExclusions (does not require PRIOR AUTHORIZATION ): * Re Self-Injectables: *Insulin *Blue Shield Pharmacy BenefitInterferonsVentavisCancidasSelf-I njectables, In-Office Injectables, InfusionsPrior AUTHORIZATION ListAnticoagulant AgentsImmune GlobulinsRocephin for Lyme Disease OnlyBebulin VHFactor VIIIF actor IXHumate-PNovosevenProplex TRecombinant Factor VIIIR ecombinant Factor IXAbraxaneAlimtaArranonClolarEloxatinFas lodexNovantroneProleukinColony Stimulating FactorsAranespEpogenVelcadeVidazaBisphos phanate AgentsBonivaAmeviveAvastinCampathErbitux ByettaProcritAnti-Rheumatic Drugs With the exception of the exclusions listed above, self-injectables, infusions and high dollar injectables require PRIOR AUTHORIZATION .

4 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. Sandostatin LAR DepoLeukineNeulastaNeumegaNeupogenZometa SynagisHerceptinLucentisMacugenRemodulin OrthoviscSupartzSynviscBotoxMyoblocNatre corSandostatinEuflexxaHyalganCopaxoneFlo lanTysabriXolairForteoMylotargRaptivaRit uxanEFFECTIVE 01/01/2010