Medical Prior Authorization List For prescription drug requirements, see plan formularies. See Separate List for Florida Hospital & Rosen Employees.

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1 For prescription drug requirements, see plan formularies. See Separate List for Florida Hospital & Rosen Employees. Effective April 15, 2016 General Information These requirements are administered by Health First Health Plans ( Health Plan ). Benefits are determined by the plan. Items listed may have limited coverage, or not be covered at all. All items and services on this list require prior authorization, regardless of the service location, plan type, or provider participation status. Referrals are not required for network specialist care. Refer to the current Provider Directory or visit our website for a list of network providers. Authorization is not a guarantee of payment. Coverage is subject to member eligibility, as well as applicable benefit and provider contract provisions on the date of service. Contract limitations may apply and supersede any authorization provided. This document is updated periodically, but may change at any time. Please refer to the current version by visiting our website at myfhca.org. See the Authorization List Code Reference for potentially-applicable procedure codes. The list is available on our website. Codes are for reference only, are not all-inclusive, and are subject to change. If waiting for a decision in the standard timeframe could seriously harm the member s life, health, or ability to regain maximum function, an expedited process is available. Yellow highlights indicate changes from last version. How to Request Authorization With the following exceptions, authorization requests should be submitted directly to the Health Plan. High Tech Imaging, Echocardiograms, and Sleep Disorder Testing and Treatment are authorized by AIM Specialty Health (AIM). Visit aimspecialtyhealth.com to request authorization and to access guidelines. Behavioral Health and Substance Abuse Services are authorized by Magellan Behavioral Health, Inc. (Magellan). Authorization may be requested by phone toll-free at HFHP (4347) or online at magellanprovider.com. To request authorization from the Health Plan, submit the appropriate medical or pharmacy (drug) Authorization Request form or request authorization online. Include applicable codes, patient identification, and clinical information to support the request. IMPORTANT CONTACTS FOR AUTHORIZATIONS SUBMITTED TO THE HEALTH PLAN Submit online requests via your secure account at myfhca.org/myportal Fax medical authorization requests to: Fax drug authorization requests to: For questions, call Customer Service toll-free at Monday through Friday from 8 a.m. to 6 p.m. Page 1 of 5

2 Effective April 15, 2016 Hospital/Skilled Nursing Facility Hospital Admissions Contracted hospitals: All procedures included on this List require prior authorization. All inpatient admissions require authorization (including hospice for Commercial members). Health First hospital admissions require notification only. Outpatient admissions do not require authorization unless the procedure itself requires it. Non-Contracted Hospitals: All procedures included on this List require prior authorization. All inpatient and outpatient admissions require authorization (including hospice for Commercial members). Admissions for Labor and Delivery do not require prior authorization. Authorization is needed if baby is admitted for medical care. Behavioral Health/Substance Abuse Services: Inpatient and outpatient hospital services (including Partial Hospitalization and Intensive Outpatient Programs) require authorization by Magellan. See How to Request Authorization for information. Skilled Nursing Facility (SNF) Services Inpatient SNF Services Outpatient Services During a Non-Covered Stay Covered services such as physician, diagnostic, and rehab services provided during a custodial stay. Diagnostic Testing Laboratory Services Genetic Testing, except standard Down Syndrome and Cystic Fibrosis screening Cologuard TM for colorectal cancer screening Radiology Services Outpatient High Tech Imaging (MRI/MRA, CT, PET) Authorized by AIM. See How to Request Authorization for information. Computed tomographic (CT) colonography (virtual colonoscopy) DaTscan SPECT Imaging to diagnose Parkinson s Echocardiograms - Authorized by AIM Specialty Health. (Fetal echos do not require prior authorization.) Cardiac Loop Recorder Implantation Orthopantograms (Panoramic X-Rays) Other Diagnostic Services Mobile Cardiac Outpatient Telemetry (MCOT) Psychological Testing Authorized by Magellan. See How to Request Authorization for information. Sleep Testing Authorized by AIM. See How to Request Authorization for information. Infertility Diagnostic Services M2A Capsule Endoscopies Investigational Items and Services Any item or service potentially considered investigational or experimental must be authorized in advance, including Category B Investigational Devices covered by Medicare. Investigational services may be described by temporary Category III CPT Codes, but may be assigned a CPT or other HCPCS code. Contact us with questions. Y0089_MPINFO3875 (03/14) Page 2 of 5

3 Effective April 15, 2016 Medical Equipment/Prosthetics/Orthotics Bone Growth Stimulators (External) Cochlear Implants/ Auditory Brainstem Implants/ Bone Anchored Hearing Aids Continuous Glucose Monitoring Long-Term; Authorization not required for 72-hour monitoring Customized DME (reported with HCPCS code K0900) Diabetic Test Supplies Non-Preferred (any supplies other than Abbott s Freestyle Lite, Freedom Lite, or Precision Xtra) Elastic Garments, Belts, Sleeves or Coverings; Authorization not required for lymphedema sleeves. Enteral/Parenteral/Oral Nutrition External Defibrillator (i.e. The Vest) Home PT/INR Monitor Hospital Beds (All) Lymphedema Pumps Neurostimulators Orthotics - See Code Reference for details. Some items may be provided in certain locations or by certain specialties without authorization. Noncovered orthotics (e.g. foot orthotics) do not require authorization. Oscillatory Devices for Airway Clearance, i.e. The Vest, Intrapulmonary Percussive Ventilation (IPV) External Prosthetic Devices [not including post-cancer breast prostheses] Positive Airway Pressure Devices (e.g. CPAP, BIPAP, APAP) Authorized by AIM every 90 days during first year of use. See How to Request Authorization for information. Authorization not required for supplies. Quantities in Excess of Medicare Guidelines Seat/Patient Lift Mechanisms Scooters Snore Guards (Oral Appliances) Noninvasive ventilator (e.g. Trilogy Vent) Wheelchairs and Accessories Physical, Occupational and Speech Therapy Services Children Under 9 Years of Age Prior authorization required for all therapy services except the initial evaluation. Individuals 9 Years of Age or Older Prior authorization is required for more than 20 physical, occupational, or speech therapy visits per calendar year. (Each discipline considered separately.) Spinal Procedures Total Disc Arthroplasties, including removal or revision Kyphoplasties/Vertebroplasties Laminectomies Spinal Fusion Spinal Instrumentation Removal of Posterior Segmental Instrumentation Thermal Intradiscal Procedures (TIPS) Y0089_MPINFO3875 (03/14) Page 3 of 5

4 Effective January 1, 2016 Other Surgical Services Bariatric Surgery, and any surgical procedure (i.e. hernia repair) performed with an obesity surgery Bronchial Thermoplasty Intacs for Keratoconus Implantation Services associated with devices that require prior authorization Penile Implants Reconstructive Procedures DIEP flap breast reconstruction requires prior authorization. Other post-cancer breast reconstruction procedures do not require authorization. Reduction Mammoplasty Sleep Apnea/Snoring Surgery Transcatheter Aortic Valve Replacement (TAVR) Select Items and Services Ambulance Services: Non-Emergency Transportation Autism Services Autologous Chondrocyte Implant Chronic Care Management (Medicare only) Dental/Maxillofacial Services EECP (Enhanced External Counterpulsation) Home Births (Planned) Incontinence Procedures including sacral nerve stimulation, tibial nerve stimulation, Renessa. Organ Transplant Services Proton Beam Therapy Radiopharmaceutical, therapeutic, not otherwise classified Skin/Wound Care (No authorization required for negative pressure wound therapy.) Skin (dermal) substitutes, i.e. AlloSkin Electrical stimulation and electromagnetic PUVA, laser treatment therapy for non-healing wounds Superficial Radiation Therapy Varicose Vein Treatment Behavioral Health - Authorized by Magellan. See How to Request Authorization. Electroconvulsive Therapy Substance Abuse Services Inpatient, Partial Hospitalization Program (PHP), and Intensive Outpatient Program (IOP) services Out-of-Network Services HMO Members With the exception of emergency care, urgently-needed care outside the service area, or renal dialysis for Medicare members, all OON services require prior authorization. POS/PPO Members (Plans with out-of-network benefits) All items and services on this list require authorization, regardless of the plan type. Page 4 of 5 See separate Authorization List for Florida Hospital Employees.

5 Effective January 1, 2016 Medical Drugs Requiring Prior Authorization (Drugs covered as medical benefits) ACTEMRA ACTHAR GEL ACTIMMUNE AFINITOR Alemtuzumab ALPHANATE APOKYN ARANESP ARCALYST ARZERRA AVEED AVONEX AVYCAZ BENLYSTA BERINERT BLINCYTO BLOOD FACTORS BOTOX CAMPATH CEREZYME CHEALAMIDE CIMZIA CINRYZE CYRAMZA DALVANCE DECA-DURABOLIN DEPOCYT DIDRONEL DISOTATE DOLOPHINE HCL DORIBAX DOXIL ELELYSO ENDRATE ENTYVIO ERBITUX ETHYOL EYLEA (not required for macular degeneration or retinal edema w/ trial of Avastin in prior 12 months.) FERAHEME FLOLAN FOLOTYN FUSILEV GAZYVA GLASSIA GRANIX HALAVEN HYCAMTIN HYQVIA ILARIS INCRELEX INJECTAFER INNOHEP Intravenous Immune Globulins ISTODAX IXEMPRA JETREA JEVTANA KALBITOR KEYTRUDA KRYSTEXXA KYPROLIS LEMTRADA LEUKINE LIPODOX LUCENTIS (not required for macular degeneration or retinal edema w/ trial of Avastin in prior 12 months.) LUMIZYME MERITATE MOZOBIL MYOBLOC MYLOTARG MYOZYME NEUMEGA NOVANTRONE NOVAREL NPLATE NULOJIX OBIZUR OCTREOSCAN OPDIVO OZURDEX PERJETA PROLASTIN PROVENGE RADIESSE REBIF REGITINE RELISTOR RETISERT RiaSTAP RITUXAN SCULPTRA SIGNIFOR SIMPONI SOLIRIS SOMATULINE SOMAVERT STELARA SUPPRELIN SYNAGIS SYNRIBO TESTOPEL TORISEL TREANDA TYSABRI TYVASO VANTAS VECTIBIX VELCADE VIBATIV VIDAZA VIMIZIM VIMPAT Viscosupplements VIVAGLOBIN VITRASERT VPRIV XEOMIN XOLAIR YERVOY ZANOSAR ZEMIRA ZERBAXA ZEVALIN ZOLADEX ZORTRESS Orphan Drugs Drugs with an orphan designation require prior authorization. Florida Hospital Care Advantage is administered by Health First Health Plans. Health First Health Plans is an HMO plan with a Medicare contract. Enrollment in Health First Health Plans depends on contract renewal. Y0089_MPINFO3877FH (03/14) Page 5 of 5 See separate Authorization List for Florida Hospital Employees.

6 Nondiscrimination Notice Florida Hospital Care Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Florida Hospital Care Advantage does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Florida Hospital Care Advantage: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, accessible electronic formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, please contact Sherri Wynn. If you believe that Florida Hospital Care Advantage has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Sherri Wynn, ADA/Section 504 Coordinator, 6450 US Highway 1, Rockledge, FL 32955, , (TTY), Fax: , Sherri Wynn@health-first.org. You can file a grievance in person or by mail, fax, or . If you need help filing a grievance Sherri Wynn, ADA/Section 504 Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Complaint forms are available at Florida Hospital Care Advantage is administered by Health First Health Plans. Health First Health Plans is an HMO plan with a Medicare contract. Enrollment in Health First Health Plans depends on contract renewal. Y0089_EL6075FH Accepted

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