REQUEST FOR PRIOR AUTHORIZATION FAX (559) …

1 REQUEST FOR PRIOR AUTHORIZATIONFAX (559) 224-2405 or (559) 224-9746 PHONE (559) 228-5400 or (800) 652-2900 OAqua TherapyOIntensity Modulated Radiation Therapy (IMRT)OBreastfeeding Medicine ReferralOM2A Video Capsule EndoscopyOBalance & Dizziness ReferralOMRI, MRA, CT & Pet ScansOColonoscopy; EGDON utrition Consult for Chronic Disease (CMC)OCosmetic/Reconstructive SurgeryOObesity - Referral to General SurgeonODME Purchase over $200 OObesity SurgeryODME RentalOOut-of-Plan ProviderOEndocrinologist Visit (Type II Diabetes)OPlastic Surgery ReferralOGenetic TestingOSleep StudiesOHome Health Home in conjunction with Health Plan ProgramsOInfusions - Ambulatory (See reverse side of this form)OWeight Management Program ReferralOInjections: Self-injectables; In-office injectablesOWound Care - Facility Based(See reverse side of this form for more information)OO NON-URGENT for routine, elective servicePatient Name: LastFirstMIDate of Birth(Mo/Day/Yr) #Other Insurance?

2 Name of Carrier?Job RelatedMVAA ccidentPregnancy Related?YesNoYesNoYes NoYesNoYesTax ID#TelephoneFaxName of PCPDatePhysician/Provider/Facility RequestedAddressFaxYes NoAnesthesiologist Required? : Yes NoName:Name:Tentative Date of Service/Admission:ICD-10 Codes(required)Diagnosis Description:Date of Onset/InjuryCPT/HCPC Codes(required) Describe Service Requested:# of Days/Visits:Comments:O CignaO Health NetO Health Net Healthy HeartO United Healthcare Medicare Solutions: Group RetireeO United Healthcare Signature ValueRequesting Physician (Please Print)PATIENT INFORMATIONFROM - REQUESTING PHYSICIANTO - WHERE WILL PATIENT RECEIVE SERVICES?TelephoneWithin 5 days before the actual date of service, provider MUST confirm that the member's health plan coverage is still in effect.

3 With the exception of urgent requests, it is recommended that you do not schedule appointments PRIOR to AUTHORIZATION approval. 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 confidential information. If the reader of this message is not the intended recipient, you are hereby notified that any distribution is strictly 2 3 Asst Surgeon Required? Today's Date:Contact Person in Requesting Provider's OfficeWhere will services be rendered? (provide name of facility, if other than provider office or patient's home)Signature of Requesting Physician1 2 3 4 CLINICAL INFORMATIONP lease check health plan:TYPE OF SERVICEO Inpatient O Outpatient O 2nd Opinion Consult O Radiology O Other:_____Gender.

4 M FURGENT for acute conditions requiring care within 72 hours or OF REQUESTSERVICES REQUIRING PRIOR AUTHORIZATION (please check requested service)O Health Net Sapphire PremierO AARP Medicare CompleteO AetnaO Blue Shield Access PlusO Brand New DayO California CareO Community Care HealthEFFECTIVE JANUARY 2018 AbraxaneEnbrelKineretRemodulinActemraEnt yvioKrystexxaRituxanActharEpogenKyprolis (Blue Shield)Rocephin for Lyme Disease OnlyActimmuneErbituxLanreotideRoferon-AA dcetris (Blue Shield)Erwinaze (Blue Shield)LeukineSaizenAldurazymeEuflexxaLo venoxSandostatinAlferon-NEyleaLucentisSa ndostatin (SC/IV)AlimtaFabrazymeMacugenSandostatin LAR Depot (IM)Alirocumab/Praluent (J3490)Factor IXMarqibo (Blue Shield)Simponi Aria (IV)AloxiFactor VIIIM ylotargSolirisAmeviveFaslodexMyoblocSoma vertAntibiotics prescribed for Lyme DiseaseFirazyrNaglazymeStelaraAralastFir magon (Blue Shield)NatrecorSupartzAranespFlolanNeula staSupprelin LA (Blue Shield)ArixtraFolotyn (Blue Shield)NeumegaSylvantArranonForteoNeupog enSynagisArzerra (Blue Shield)FragminNovantroneSynribo (Blue Shield)AvastinFuzeonNovosevenSynvisc, Synvisc One, Gel OneAveedGazyvaNplateTestopelAvonexGenotr opinOrenciaTorisel (Blue Shield)Bebulin VHHalaven (Blue Shield)OrthoviscTreanda (Blue Shield)Beleodaq (Blue Shield)HerceptinOzurdexTysabriBenylstaHi zentraPegasysTyvasoBetaseronHumate-PPEG- IntronVectibix (Blue Shield)BonivaHumatropePerjeta (Blue Shield)VelcadeBotoxHumiraPrialtVelcade (Blue Shield)

5 ByettaHyalganProcritVentavisCampathIlari sProlastinVidazaCancidasIluvienProleukin VimizimCeredaseIncrelexProliaVivaglobuli nCerezymeInfergenProplex TXgevaCimziaInnohepQutenzaXiaflexCinryze Intravenous Immune Globulin VariousRaptivaXolairClolarIntron-ARebetr onYervoy (Blue Shield)CopaxoneIstodax (Blue Shield)RebifZaltrap (Blue Shield)CyramzaIxempra (Blue Shield)ReclastZemairaCytoGamJetreaRecomb inant Factor IXZevalin (diagnostic)DacogenJevtana (Blue Shield)Recombinant Factor VIIIZ evalin (therapeutic)DalvanceKadcyla (Blue Shield)RemicadeZometaEloxatinKalbitorExc lusions (does not require PRIOR AUTHORIZATION ): *Re Self-Injectables:*Insulin*Blue Shield Pharmacy BenefitSelf-Injectables, In-Office Injectables, InfusionsPrior AUTHORIZATION List With the exception of the exclusions listed above, self-injectables, infusions and high dollar injectables require PRIOR AUTHORIZATION .

6 This list does not contain every item requiring PRIOR AUTHORIZATION . If unsure, check with Sant UM staff if you are ordering/administering an infusion, self-injectable or high dollar injectable that is not listed here.