Medicare Advantage 2017 Precertification Requirements (Effective for January 1, 2017 to December 31, 2017) The following Medicare Advantage plans require precertification i from in network providers. Call the telephone number listed on the back of the member’s identification card for precertification, verification of member eligibility, benefits and account information. This document provides a general list of all Precertification requirements. Detailed Prior Authorization requirements are available to the contracted provider by accessing the “Provider Self-Service Tool” within Availity. Contracted and Non-contracted providers should contact the Health Plan if they are not able to access Availity. Medicare Advantage Plans requiring in-network provider precertification. • • •

HMO Plans – all contracted network providers. PPO Plans – all contracted network providers. PPO Plans – all non-contracted out of network providers are encouraged to call

Plan States: CA, CO, GA, OH, IN, KY, MO, WI, NY, CT, NH, ME, VA NOTE: There is a national service area for select Employer Group Retiree Medicare Advantage plans. Precertification is the determination that selected medical services meet medical necessity criteria under the member's benefits contract. For the member to receive maximum benefits, the health plan must authorize or “precertify” these covered services prior to being rendered. Precertification includes a review of both the service and the setting. Care will be covered according to the member's benefits for the services and/or number of days precertified unless our concurrent review determines that additional services and/or days do not qualify for coverage. Certain services may require the member to use a provider designated by the health plan’s Utilization Management staff. A copy of the approval will be provided to you, the physician and the hospital or facility. For benefits to be paid the member must be eligible for benefits and the service must be a covered benefit under the contract at the time the services are rendered.

Precertification Responsibility For HMO type health plans: It is the participating physician’s or provider’s responsibility to contact the health plan’s Utilization Management Department to obtain precertification. The request must come from the provider or facility rendering the service, not the referring physician. If precertification is not obtained, the claim is denied by the Plan and the member must be held harmless. The Precertification number is listed on the back of the member’s health plan ID card. For PPO type health plans: It is the network provider’s responsibility to contact the health plan’s Utilization Management Department to obtain precertification. If precertification is not obtained when the service is from a network provider, the claim is denied by the Plan and the member must be held harmless. Claims from out of network providers will typically pend for a medical necessity review prior to payment if associated with a service in this document. The Precertification number is listed on the back of the member’s health plan ID card.

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Inpatient Admissions Also see Behavioral Health and Transplants sections for precertification requirements.  The health plan must be notified of emergency admissions or transfers within 1 business day of admission.  Precertification required for non-emergent inpatient transfers between acute facilities.  Precertification is required for the following services prior to admission: o Elective Inpatient Admissions o Rehabilitation Facility admissions o Long Term Acute Care (LTAC) o Skilled Nursing Facility admissions  Precertification is NOT required, however notice is requested for all members initiating dialysis treatment.

Select Outpatient Services This is not a comprehensive list and is included here as a guide on when to call for precertification. If the service is listed you are required to call for precertification. Detailed Prior Authorization requirements are available to the contracted provider by accessing the “Provider Self-Service Tool” within Availity. Contracted and Non-contracted providers should contact the Health Plan if they are not able to access Availity. [New in 2017]  [Coronary Artery Bypass Graft (CABG)]  [Home Health and Home Infusion] Continuing in 2017  Breast Reconstruction  Spine Procedures  Cervical Fusions  Arthroscopies/Arthroplasties  Defibrillator/Pacemaker Insertion or Replacement  Endoscopies  Hyperbaric Oxygen Therapy  Laparoscopies  Laminectomies/Laminotomies  Tonsillectomy/Adenoidectomy  Nerve Destructions  Sleep Studies and Sleep Study related equipment and supplies  UPPP surgery (Uvulopalatopharyngoplasty - removal of excessive soft tissue in the back of the throat to relieve obstruction)  Bariatric/Gastric Obesity Surgery  All potentially Cosmetic surgeries  Non-emergent ground, air and water transportation  Occupational Therapy  Physical Therapy  Pain Management 2

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Chiropractic Care (New York and Connecticut only) Oncology (Breast), mRNA, Gene Expression Profiling Radiation Therapy Vascular Angioplasty and Stents Vascular Ultrasound Knee and Hip Replacements Radiation Oncology Knee Orthoses Spinal Orthoses Vascular Embolization and Occlusion Services

DME/Prosthetics Precertification is required for the following services (to include, but not limited to). Detailed Prior Authorization requirements are available to the contracted provider by accessing the “Provider SelfService Tool” within Availity. Contracted and Non-contracted providers should contact the Health Plan if they are not able to access Availity.  Prosthetics, Orthotics  Power Wheelchairs, Accessories, and POV  Non-Standard Wheelchairs  Non-Standards Beds  Patient Transfer Systems  Speech Generating Devices and accessories  Sleep Study related equipment and supplies

Radiology Services Precertification is required for the following services. Detailed Prior Authorization requirements are available to the contracted provider by accessing the “Provider Self-Service Tool” within Availity. Contracted and Non-contracted providers should contact the Health Plan if they are not able to access Availity.  PET  Nuclear Cardiac  CT Scan (includes CTA)  MRI  MRA  MRS  Echocardiograms  Radiation Therapy  Radiation Oncology Behavioral Health Services Mental Health/ Substance Abuse Services: Specially trained professionals will handle referrals and coordinate care for mental health and substance abuse. This includes: referrals to mental health and substance abuse treatment providers, general information about mental health and substance abuse benefits and treatment, emergency and urgent care information and assistance 3

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Plan must be notified of emergency admissions within 1 business day of admission. Precertification is required for: o Inpatient Admissions o Rehabilitation Facility admissions. Rehabilitation requires precertification but benefit availability is limited. Please be sure to check the member’s benefits. o Day Hospital/Partial Hospital admissions o Intensive Outpatient therapy o Psychological and Neuropsychological Testing o Transcranial Magnetic Stimulation (TMS) for depression

Transplants: Human Organ and Bone Marrow/Stem Cell Transplants Precertification is required for Medicare Covered Transplant admissions. All Inpatient admissions for the following:  Heart transplant  Liver transplant  Lung or double lung transplant  Simultaneous Pancreas/ Kidney  Pancreas transplant  Kidney transplant  Small bowel transplant  Multi-visceral transplant  Stem cell/Bone Marrow transplant (with or without myeloablative therapy)  Islet Cell transplant All Outpatient services for the following:  Stem Cell/ Bone Marrow transplant (with or without myeloablative therapy)  Donor Leukocyte Infusion

Specialty Pharmacy Part D drugs - Requirements for Tiers, Prior Authorization, Quantity Limits and Step Therapy are found in the plan specific formularies. The following link to our formularies is also available for more information regarding Part D drugs: https://www.anthem.com/wps/portal/ahpmedprovider?content_path=shared/noapplication/f4/s2/ t0/pw_e240965.htm&label=Anthem%20Blue%20Cross%20and%20Blue%20Shield&rootLevel=0 Part B drugs – Refer to the Appendix for a general list of drugs paid under the medical benefit requiring precertification. Detailed Prior Authorization requirements are available to the contracted provider by accessing the “Provider Self-Service Tool” within Availity. Contracted and Noncontracted providers should contact the Health Plan if they are not able to access Availity.

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APPENDIX This is not a comprehensive list and is included here as a guide on when to call for precertification. If the Part B drug is listed here you are required to call for precertification. The HCPCS code to the Part B drug is the one assigned at the time of this notice. Detailed Prior Authorization requirements are available to the contracted provider by accessing the “Provider Self-Service Tool” within Availity. Contracted and Non-contracted providers should contact the Health Plan if they are not able to access Availity. HCPCS Code A9699 C9137 C9138 C9257 C9473 C9476 C9477 J0129 J0135 J0178 J0202 J0485 J0490 J0585 J0586 J0587 J0588 J0881 J0885 J0897 J1300 J1325 J1438 J1442 J1447 J1453 J1459 J1556 J1557 J1559 J1561

Drug(s) XOFIGO FACTOR VIII, PEGylated FACTOR VIII, NUWIQ AVASTIN, BEVACIZUMAB NUCALA DARZALEX EMPLICITI ABATACEPT, ORENCIA ADALIMUMAB, HUMIRA PEN EYLEA LEMTRADA NULOJIX, BELATACEPT BENLYSTA BOTOX, ONABOTULINUMTOXINA DYSPORT MYOBLOC INCOBOTULINUMTOXINA ARANESP, ARANESP (ALBUMIN FREE), DARBEPOETIN ALFA-POLYSORBATE EPOETIN ALFA, EPOGEN, PROCRIT DENOSUMAB, PROLIA, XGEVA SOLIRIS FLOLAN, EPOPROSTENOL ENBREL, ENANERCEPT FILGRASTIM, NEUPOGEN GRANIX EMEND PRIVIGEN BIVIGAM, IVIG GAMMAPLEX, IMMUNE GLOBULIN HIZENTRA, IMMUNE GLOBULIN GAMMAKED, GAMUNEX-C 5

Effective Date before 2015 4/1/2016* 4/1/2016* before 2015 4/1/2016* 11/1/2016* 11/1/2016* before 2015 before 2015 1/1/2015 1/1/2015 9/1/2015 2/22/2015 before 2015 before 2015 before 2015 before 2015 before 2015 before 2015 before 2015 before 2015 before 2015 before 2015 before 2015 before 2015 11/1/2016* before 2015 before 2015 before 2015 before 2015 before 2015

HCPCS Code J1566 J1568 J1569 J1572 J1575 J1602 J1740 J1745 J1950

Drug(s)

CARIMUNE NF OCTAGAM GAMMAGARD, GAMMAGARD S/D FLEBOGAMMA, IMMUNE GLOBULIN HYQVIA (IVIG) SIMPONI ARIA BONIVA INFLIXIMAB, REMICADE LEUPROLIDE ACETATE, LEUPROLIDE ACETATE (3 MONTH, 4 MONTH, 6 MONTH), LUPRON DEPOT J2278 PRIALT, ZICONOTIDE J2323 NATALIZUMAB J2353 OCTREOTIDE ACETATE, SANDOSTATIN LAR DEPOT J2354 OCTREOTIDE ACETATE J2355 NEUMEGA J2357 OMALIZUMAB, XOLAIR J2469 ALOXI J2503 MACUGEN, PEGAPTANIB J2505 NEULASTA J2507 KRYSTEXXA J2778 LUCENTIS, RANIBIZUMAB J2796 NPLATE J2820 LEUKINE, PROKINE J2860 SYLVANT J2941 HUMATROPE, NUTROPIN, SOMATROPIN J3262 ACTEMRA J3285 REMODULIN J3380 ENTYVIO J3489 RECLAST, ZOLEDRONIC ACID, ZOMETA J3490 GENERIC CODE, UNCLASSIFIED DRUGS J3490 TESTOPEL J3490 REPATHA J3490 PRALUENT J3590 (MOST COMMONLY USED FOR AVASTIN EYE), UNCLASSIFIED BIOLOGICS J3590 AFSTYLA J3590/J3 TALTZ 490 J7178 HUMAN FIBRINOGEN

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Effective Date before 2015 before 2015 before 2015 before 2015 1/1/2016* 1/1/2015 2/1/2016* before 2015 1/1/2015 before 2015 before 2015 before 2015 before 2015 5/1/2015 before 2015 11/1/2016* before 2015 before 2015 5/1/2015 before 2015 5/1/2015 before 2015 1/1/2016* before 2015 before 2015 before 2015 7/1/2015 before 2015 before 2015 before 2015 1/1/2016* 1/1/2016* **compound use** 11/1/2016* 12/1/2016* 5/1/2015

HCPCS Code J7180 J7181 J7182 J7183 J7185 J7186 J7187 J7188 J7189 J7190 J7191 J7192 J7193 J7194 J7195 J7198 J7199 J7200 J7201 J7205 J7311 J7312 J7313 J7316 J7321 J7323 J7324 J7325 J7327 J7328 J7340 J7686 J9010 J9015 J9035 J9039 J9042 J9043

Drug(s) FACTOR XIII FACTOR XIII A-SUBUNIT FACTOR VIII - NOVOEIGHT VON WILLEBRAND FACTOR COMPLEX - WILATE FACTOR VIII - XYNTHA VON WILLEBRAND FACTOR COMPLEX -ALPHANATE VON WILLEBRAND FACTOR COMPLEX - HUMATE P FACTOR VIII FACTOR VIIa FACTOR VIII - HEMOFIL M, DOATE DVI, MONOCLATE-P FACTOR VIII (PORCINE) FACTOR VIII - ADVATE, HELIXATE-FS, KOGENATE-FS FACTOR IX - ALPHANINE SD, MONONINE FACTOR IX COMPLEX - BEBULIN VH, PROFILNINE SD FACTOR IX - BENEFIX ANTI-INHIBITOR HEMOPHILIA CLOTTING FACTOR - ELOCTATE FACTOR IX - RIXUBIS FACTOR IX - FC FUSION PROTIEN (RECOMBINANT) FACTOR VIII RETISERT, FLUOCINOLONE IMPLANT OZURDEX ILLUVIEN JETREA HYALGAN, SODIUM HYALURONATE (VISCOSUP), SUPARTZ EUFLEXXA HYALURONAN, ORTHOVISC HYALURONIC ACID, HYLAN, SYNVISC, SYNVISC ONE MONOVISC GEL-ONE DUOPA TYVASO, TREPROSTINIL CAMPATH PROLEUKIN AVASTIN BLINCYTO ADCETRIS JEVTANA 7

Effective Date 7/1/2015 7/1/2015 7/1/2015 7/1/2015 7/1/2015 7/1/2015 7/1/2015 7/1/2015 7/1/2015 7/1/2015 7/1/2015 7/1/2015 7/1/2015 7/1/2015 7/1/2015 7/1/2015 7/1/2015 7/1/2015 7/1/2015 7/1/2015 7/1/2015 before 2015 before 2015 before 2015 before 2015 before 2015 before 2015 before 2015 before 2015 before 2015 1/1/2016* before 2015 before 2015 before 2015 before 2015 8/1/2015 before 2015 before 2015

HCPCS Code J9047 J9055 J9155 J9179 J9202 J9207 J9217 J9218 J9219 J9228 J9262 J9264 J9266 J9271 J9299 J9301 J9302 J9303 J9305 J9306 J9308 J9310 J9315 J9351 J9354 J9355 J9400 Q0515 Q2043 Q4074 Q5101 Q9980

Drug(s) KYPROLIS ERBITUX FIRMAGON HALAVEN GOSERELIN ACETATE IMPLANT, ZOLADEX IXEMPRA LEUPROLIDE ACETATE (3 MONTH, 4 MONTH, 6 MONTH), LUPRON DEPOT LEUPROLIDE ACETATE LEUPROLIDE ACETATE IMPLANT YERVOY SYNRIBO ABRAXANE ONCASPAR KEYTRUDA OPDIVO GAZYVA ARZERRA VECTIBIX ALIMTA PERJETA CYRAMZA RITUXAN ISTODAX HYCAMTIN KADCYLA HERCEPTIN ZALTRAP GEREF, SERISTIM PROVENGE VENTAVIS ZARXIO GENVISC

Effective Date before 2015 before 2015 before 2015 before 2015 before 2015 12/1/2016* before 2015 before 2015 before 2015 before 2015 11/1/2015 1/1/2015 1/1/2016* before 2015 1/9/2015 4/30/2015 1/1/2015 before 2015 before 2015 before 2015 10/1/2015 before 2015 12/1/2016* before 2015 1/1/2015 before 2015 before 2015 before 2015 before 2015 5/1/2015 9/1/2015 1/1/2016*

* Indicates new code Precertification requirements document is posted to the Medicare Advantage Provider Portals.

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Precertification – For the purpose of this document, precertification (aka - prior authorization) indicates a requirement to precertify prior to rendering a service which includes authorization of additional days on concurrent review. Out of network providers may optionally choose to call the health plan to obtain precertification (or a predetermination) regarding whether a service meets benefit and medical necessity criteria. 61269MUSENMUB 08/10/16

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