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1 To: From: All SCFHP Contracted Providers Health Services-Utilization Management Date: December 21, 2017 Subject: Dear Providers: 2018 Prior Authorization Grid Thank you for your continued care of Santa Clara Family Health Plan members. We would like to share information about changes in our prior authorization requirements that will become effective for dates of service on or after January 1, The Prior Authorization Grids indicating services that require prior authorization have been updated for all lines of business and are attached for your convenience. The following is a summary of the 2018 changes by line of business: Cal MediConnect: Added Removed Other Changes Cataract Surgery Penile Implant Outpatient therapy will now require PA from start of care instead of before the 12th visit Jaw Surgery, Orthognathic procedures including TMJ treatment Collection of autologous blood Sleep Studies Medi-Cal only benefit: LTC, MSSP Spinraza/Nusinersen (Drug) Ocrevus/Ocrelizumab (Drug) Medi-Cal and Healthy Kids: Added Removed Other Changes Orthognathic procedures, including TMJ treatment Wound care, including wound vac Update to the phone number for County Behavioral Health Spinraza/Nusinersen (Drug) IHSS Ocrevus/Ocrelizumab (Drug) For the full list, please see the attached 2018 Prior Authorization Grids for Cal MediConnect and Medi-Cal/Healthy Kids. If you have any questions regarding this information, please contact SCFHP UM department at _PS_2018 PA Grid_V1
2 Organizational Determination Requirements (Prior Authorization Grid) for Cal MediConnect 2018 Organizational Determination Telephone Line: Organizational Determination Fax Line: or Other Contact Information: Eligibility: Customer Service: Provider Services: Note: The following services are subject to Organizational Determination requirements. When faxing a request, please attach pertinent medical records, treatment plans, test results, and evidence of conservative treatment to support the medical appropriateness of the request. This Organizational Determination list contains services that require Organizational Determination only and is not intended to be a list of covered services. Providers should refer to an enrollee s Member Handbook (Evidence of Coverage (EOC)) for a complete list of covered services. For dental care please contact Denti-Cal at For vision care, please contact VSP at Non-participating provider Inpatient Admissions, Services and Therapy Outpatient Procedures/Surgery All services Acute Hospital (including Psychiatric) Acute Rehabilitation Facilities All elective medical and surgical inpatient hospitalizations Long Term Acute Care (LTAC) Partial hospital/residential Treatment for Mental health, Substance Use disorder Skilled Nursing Facilities (SNF) Physical/Occupational/Speech Therapy (PT/OT/ST) Abdominoplasty Bariatric procedure Blepharoplasty Breast reductions and augmentation Cataract surgery Cochlear auditory implant Dental surgery, jaw surgery and orthognathic procedures including TMJ treatment Dermatology procedure: Laser treatment, Skin injections and implants Experimental/investigational procedures/services and new technologies Neuro and spinal cord stimulator Panniculectomy Plastic surgery reconstructive procedures Spinal surgery Surgery for obstructive sleep apnea Varicose vein treatment P CMC PriorAuthGrid 1 Effective Date: 01/1/2018
3 Outpatient Services Cardiac and Pulmonary Rehabilitation Collection of autologous blood Genetic testing and counseling Hyperbaric oxygen therapy Outpatient diagnostic procedures: Magnetic resonance imaging (MRI), Magnetic resonance angiography (MRA), Magnetic resonance Spectroscopy, Nuclear cardiology procedures (including SPECT), Positron-emission tomography (PET), Sleep studies. Outpatient Physical/Occupational/Speech therapy (PT/OT/ST Radiation therapy: Intensity modulated radiation therapy (IMRT), Proton beam therapy, Stereotactic radiation treatment (SBRT), Neutron beam therapy Sleep studies Transplant-related services (EXCEPT Cornea transplant): prior to evaluation. Durable Medical Equipment (DME) Custom made items Any other DME or medical supply item exceeding $1000 allowable Prosthetics & customized Orthotics exceeding $1000 allowable Home Health Home Health service Home IV Infusion service Part B drugs administered in a Physician s office or Outpatient setting Part B drugs - See 2018 Medicare Part B Specialty Drug Organizational Determination List (attached) Medi-Cal only benefit Hearing aids Incontinence supplies exceeding $165 per month or non-formulary Community Based Adult Services (CBAS) Long Term Care Multipurpose Senior Services Program (MSSP): No PAR, authorized by Sourcewise Fax Referrals to: Referral to SCFHP MLTSS Team for timely LTSS access Transportation Non-Emergency Medical Transportation for ground and air Schedule routine non-emergency medical transportation in area through SCFHP Customer Service at
4 Medicare Part B Specialty Drug Organizational Determination List 2018 ANTIEMETICS (ASSOCIATED WITH CANCER CHEMOTHERAPY) Aloxi Palonosetron Emend Aprepitant Emend IV Fosaprepitant NEUROMUSCULAR BLOCKING AGENTS Botox OnabotulinumtoxinA Dysport AbobotulinumtoxinA Myobloc RimabotulinumtoxinB Xeomin IncobotulinumtoxinA ERYTHROPOIESIS STIMULATING AGENTS Aranesp Epogen, Procrit Darbepoetin alfa Epoetin alfa GAUCHER'S DISEASE Cerezyme Imiglucerase Elelyso Taliglucerase Vpriv Velaglucerase HEREDITARY ANGIOEDEMA Berinert, Cinryze Compliment C1 esterase inhibitor Kalbitor Ecallantide IV IMMUNOGLOBULIN (IVIG) Baygam, Flebogamma, Gamastan, Gammagard, Gammaplex, Gamunex, Gamunex-C, Hizentra, Octagam, Privigen, Vivaglobin Immune globulin 3
5 MULTIPLE SCLEROSIS Tysabri Ocrevus Natalizumab Ocrelizumab OPHTHALMIC AGENTS Eylea Lucentis Aflibercept Ranibizumab OSTEOPOROSIS OR BONE MODIFIERS Aredia Pamidronate PULMONARY HYPERTENSION Flolan Veletri Remodulin Epoprostenol Treprostinil RHEUMATOLOGY/IMMUNOSUPPRESSANTS Actemra Orencia Remicade Inflectra Stelara Tocilizumab Abatacept Infliximab Infliximab-dyyb Ustekinumab RESPIRATORY Aralast, Aralast NP, Glassia, Prolastin, Prolastin C, Zemaira Cinqair Nucala Xolair Synagis α-1 proteinase inhibitor Reslizumab Mepolizumab Omalizumab Palivizumab MISCELLANEOUS Nplate Spinraza Romiplostim Nusinersen 4
6 Prior Authorization Request Telephone Line: Prior Authorization Request Fax Line: or Other Contact Information: Eligibility: Customer Service: Provider Services: Prior Authorization Grid for Medi-Cal and Healthy Kids 2018 Note: When faxing a request, please use SCFHP Prior Authorization Request Medical Services form found at attach pertinent medical records, treatment plans, test results, and evidence of conservative treatment to support medical necessity. This Prior Authorization Grid contains services that require prior authorization only and is not intended to be a list of covered services. Providers should refer to an enrollee s Evidence of Coverage (EOC) for a complete list of covered services. For dental care for Medi-Cal members, please contact Denti-Cal at For dental care for Healthy Kids members, please contact Liberty Dental at For vision care, please contact VSP at Non-Contracted Provider Inpatient Admissions, Services and Therapy Outpatient Procedures/Surgery ALL SERVICES All elective medical and surgical inpatient admissions Acute hospital (including psychiatric) Acute rehabilitation facilities Long Term Acute Care (LTAC) Partial hospital psychiatric treatment, substance use disorder including detoxification Skilled Nursing Facilities (SNF) - Skilled, custodial and long-term care Abdominoplasty/Panniculectomy Bariatric procedure Breast reconstructive surgery Cataract surgery Cochlear auditory implant Dental surgery, jaw surgery and orthognathic procedures including TMJ treatment) Dermatology procedures: Laser treatment, skin injections and implants Endoscopy, colonoscopy, esophagogastroduodenoscopy (EGD) Experimental/investigational procedures/services and new technologies Gender reassignment surgery Neuro and spinal cord stimulator Plastic surgery reconstructive procedures, including Blepharoplasty, Rhinoplasty, Tracheoplasty Podiatric procedures and surgery Spinal procedures, excepting epidural injections Surgery for obstructive sleep apnea Varicose vein treatment P MC PriorAuthGrid 1 Effective Date: 01/1/2018
7 Durable Medical Equipment (DME) Most DME is capitated to CHME, FAX to Enteral nutrition Incontinence supplies Home medical equipment: walkers, wheelchairs, commodes Mobility devices including motorized wheelchairs and scooters Respiratory: Oxygen, BIPAP, CPAP, ventilators Specialty DME: PAR should be submitted to SCFHP, including: Prosthetics and orthotics Hearing aids Other specialty devices Outpatient Services Cardiac and pulmonary rehabilitation Collection of autologous blood EEG, EMG, NCV Genetic testing and counseling Hyperbaric oxygen therapy Radiation therapy: Intensity modulated radiation therapy (IMRT), proton beam therapy, stereotactic radiation treatment (SBRT), neutron beam therapy Outpatient diagnostic imaging: Magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), nuclear cardiology procedures (including SPECT), positron-emission tomography (PET), Outpatient physical/occupational/speech therapy (PT/OT/ST) Sleep studies Transplant-related services (EXCEPT Cornea transplant): prior to surgery Home Health All home health services Home IV infusion services Drugs Administered in Office or See attached Medi-Cal drug PA list Outpatient setting Transportation Non-Emergency Medical Transportation for ground and air Schedule routine non-emergency medical transportation in area through SCFHP Customer Service at Organ Transplant Kidney and corneal transplants Other organs transplant: Contact SCFHP for enrollment in FFS Medi-Cal Behavioral Health Treatment (Autism) Mental Health Services Substance Abuse Treatment Long-Term Services and Supports (LTSS) Behavioral Health Treatment (Autism): Requires PAR. Includes ST, PT, and OT with Autism dx Mental Health Services: No PAR. Specialty MH services authorized by County Behavioral Services Department Substance Abuse Treatment: No PAR for SBIRT, all other are provided through the County Gateway access Community-Based Adult Services (CBAS) Long Term Care Multipurpose Senior Services Program (MSSP): No PAR, authorized by Sourcewise Fax Referrals to: Referral to SCFHP MLTSS Team for timely LTSS access
8 Medical Benefit Drug Prior Authorization Grid for Medi-Cal and Healthy Kids 2018 ANTIEMETICS (ASSOCIATED WITH CANCER CHEMOTHERAPY) Aloxi Emend Emend IV Palonosetron Aprepitant Fosaprepitant NEUROMUSCULAR BLOCKING AGENTS Botox Dysport Myobloc Xeomin OnabotulinumtoxinA AbobotulinumtoxinA RimabotulinumtoxinB IncobotulinumtoxinA ERYTHROPOIESIS STIMULATING AGENTS Aranesp Epogen, Procrit Darbepoetin alfa Epoetin alfa GAUCHER'S DISEASE Cerezyme Elelyso Vpriv Imiglucerase Taliglucerase Velaglucerase HEREDITARY ANGIOEDEMA Berinert, Cinryze Kalbitor Compliment C1 esterase inhibitor Ecallantide IV IMMUNOGLOBULIN (IVIG) Baygam, Flebogamma, Gamastan, Gammagard, Gammaplex, Gamunex, Gamunex-C, Hizentra, Octagam, Privigen, Vivaglobin Prolia; Xgeva Reclast, Zometa Immune globulin Denosumab Zoledronic acid 3
9 MULTIPLE SCLEROSIS Tysabri Ocrevus Natalizumab Ocrelizumab OPHTHALMIC AGENTS Eylea Lucentis Aflibercept Ranibizumab OSTEOPOROSIS OR BONE MODIFIERS Aredia Pamidronate PULMONARY HYPERTENSION Flolan Veletri Remodulin Epoprostenol Treprostinil RHEUMATOLOGY/IMMUNOSUPPRESSANTS Actemra Orencia Remicade Inflectra Stelara Tocilizumab Abatacept Infliximab Infliximab-dyyb Ustekinumab RESPIRATORY Aralast, Aralast NP, Glassia, Prolastin, Prolastin C, Zemaira Cinqair Nucala Xolair Synagis α-1 proteinase inhibitor Reslizumab Mepolizumab Omalizumab Palivizumab MISCELLANEOUS Nplate Spinraza Romiplostim Nusinersen 4
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