Table of Contents – Effective 10/01/2020

BCBSAZ Precertification Requirements for 2020

TABLE OF CONTENTS Revisions to table of contents or one or more of the following lists: Effective 10/01/2020

PRECERTIFICATION REQUIREMENTS LISTS MEMBER ID PREFIXES PAGE REVISED

BCBSAZ standard precertification requirements (list for most BCBSAZ members) See precert code list at azblue.com/providers > Practice Management > Precertification

Pages 1-3 Effective 10/01/20

PPO (Statewide) XBB, XBM, XBP, Z3J, Z4E, Z4M, Z4P, Z4X

PPO Alliance XBN, Z4A, Z5M

PPO PimaConnect PMA

Indemnity XBC, XBD

HMO (see below for PCP Coordinated Care HMO) XBK, XBO

Large employer groups Note: Excludes the groups listed below that have customized precertification requirements.

Prefixes vary (some groups have unique prefixes)

PCP Coordinated Care HMO plans FLH, FQL, NNG, NNJ, PMK, XAH, XHK Pages 4-5 10/01/20

Lists for employer group plans with customized precertification requirements:

Amkor Technology, Inc. (Group # 039176) K8Y, K8Z Page 6 05/12/20

City of Phoenix (Group #s 040000 and 040004) PXO Page 7 10/01/20 Northwest Arizona Employee Benefit Trust (NAEBT) (Group # 037461) NBT Page 8 06/12/19

OB Sports Golf Management, LLC (Group # 038043)

OBT Page 9 08/06/19

Snell & Wilmer (Group # 030313) SWB, SNK Page 10 10/01/20

State of Arizona (Group # 030855) SYD, S3Z Page 11 10/01/20

Teamsters (Group #s 031843 and 031844) TYW Page 12 10/01/20

Federal Employee Program® (FEP®) list R Pages 13-14 01/01/20

GENERAL DISCLAIMERS Precertification is not a guarantee of payment.

Precertification requirements are determined and governed by the member’s benefit plan. Some large groups customize their precertificationrequirements. Refer to the large group custom precertification lists for these groups.

The precertification requirements lists in this document are intended as a general summary only and are subject to change without notice.

Precertification approval decisions are based on information provided during the request process. To complete a precertification, medical records may be requested.

Although precertification may not be required for a particular service, the claim for the service may still be subject to review for medical necessity, as well as benefits, limitations, exclusions, and waivers, if applicable. For further predetermination research, you can use thefollowing resources in the secure provider portal at azblue.com/providers: eligibility and benefits inquiry (includes benefit plan summaries), InterQual® clinical criteria search, pharmacy coverage guidelines, and Clear Claim Connection™ (C3) code edit transparency tool.

Penalties: Any provider can initiate a precert request. If the required precertification is not obtained prior to service, the penalty is applied to: A) the contracted servicing provider or facility, or B) the member, if an out-of-network provider or facility is used.

BCBSAZ Standard Precertification Requirements List PPO (includes PPO Alliance and PPO PimaConnect), Indemnity, and HMO (PCP Coordinated Care HMO plans have different requirements, dedicated fax and phone numbers, and a separate online tool for precertification requests. See pages 4-5.)

Standard Precertification List – Effective 10/01/2020 Page 1

The list below displays standard precertification requirements for most BCBSAZ members. Yellow highlight = eviCore precertification program (to determine if a member requires precert through eviCore for certain services or drugs, check eligibility and benefits; select service type 30 “Health Benefit Plan Coverage”) See standard precertification code list at azblue.com/providers > Practice Management > Precertification

2020 STANDARD PRECERTIFICATION REQUIREMENTS – for most BCBSAZ members

• Please use the BCBSAZ online tool for precertification requests. • For members delegated for the eviCore program (check eligibility and benefits), use the

eviCore online request tool as indicated in this list. NOTES for 2020

Clinical trials Requires precertification or notification

Dental-related facility services or dental-related services integral to medical services when scheduled as an inpatient admission

Use BCBSAZ online request tool Or call 602-864-4320 / 1-800-232-2345

Diagnostic testing/monitoring (certain tests and studies)

Use BCBSAZ online request tool Or call 602-864-4320 / 1-800-232-2345

Durable medical equipment (DME)

Extended active rehabilitation (EAR): Inpatient rehabilitation services

Home health services

Hospice services

Infusion/IV therapy in any setting (hospital outpatient, physician’s office, infusion center, home infusion) covered under medical benefits. Certain drugs may have coverage criteria, including a site-of-service review.

Drugs covered under MEDICAL PA requirements: Precert Lookup Tool or the BCBSAZ Members-Precert Code List-Standard (secure provider portal) PA requests: BCBSAZ Members-Online request tool (secure provider portal) or: 602-864-4320 or 1-800-232-2345.

Drugs covered under PHARMACY PA requirements/requests: Standard Pharmacy Plans or: 1-866-325-1794.

Injectable medications that must be administered by a healthcare professional may require precertification and are billed under medical benefits.

Injectable and oral medications that can be self-administered may require prior authorization and are billed under pharmacy benefits.

Inpatient admission • All scheduled admissions require precertification. • Detoxification admissions require precertification. • All emergency admissions, including medical, surgical, maternity, and behavioral

health/substance abuse admissions, require notification within 48 hours of admission. • Bariatric surgery for HMO members only: The site of service for bariatric surgery must be

a Blue Distinction Center for Specialty Care (BDSC).

Use BCBSAZ online request tool Or call 602-864-4320 / 1-800-232-2345

To find Blue Distinction Centers for bariatric surgery: BCBS Blue Distinction

Facility Search tool

LAB MANAGEMENT for genetic testing, including hereditary cancer syndromes (e.g., BRCA), carrier screening tests, tumor marker/molecular profiling, hereditary cardiac disorders, cardiovascular disease and thrombosis risk variant testing, pharmacogenomics testing, neurologic disorders, mitochondrial disease testing, intellectual disability/developmental disorders

Check eligibility and benefits for eviCore delegation (select service type 30, “Health

Benefit Plan Coverage”).

See specific code list and use the eviCore online request tool.

Members not delegated for eviCore require precert through BCBSAZ for

these services. Use BCBSAZ online request tool

Or call 602-864-4320 / 1-800-232-2345

Lab services not included in the eviCore program: Fertility services, HIV screening Use BCBSAZ online request tool Or call 602-864-4320 / 1-800-232-2345

Standard Precertification List – Effective 10/01/2020 Page 2

Long-term acute care (LTAC) Use BCBSAZ online request tool Or call 602-864-4320 / 1-800-232-2345

MEDICAL ONCOLOGY: All medical oncology and hematology services in the following categories: infused drugs (may include site-of-service requirements), supportive agents, companion diagnostics/personalized medicine

Check eligibility and benefits for eviCore delegation (select service type 30, “Health

Benefit Plan Coverage”). See specific code list and use the eviCore

online request tool.

Members not delegated for eviCore require precert through BCBSAZ for the

services. Use BCBSAZ online request tool

Or call 602-864-4320 / 1-800-232-2345

Out-of-network provider See footnotes 1, 2

Outpatient surgery and related procedures or services, including but not limited to: • Bariatric surgery (site-of-service requirements apply for members with HMO plans) • Breast surgery • Dermatology procedures • Device insertion/implant • Repair and reconstructive surgeries • Musculoskeletal procedures: joint replacement, spine surgery, interventional pain management

procedures • Carpal tunnel • Hysterectomy • Varicose vein surgeries

Use BCBSAZ online request tool Or call 602-864-4320 / 1-800-232-2345

To find Blue Distinction Centers for bariatric surgery: BCBS Blue Distinction

Facility Search tool

RADIATION THERAPY treatment techniques, including clinical modalities such as: 2D, 3D conformal/IMRT/brachytherapy/SRS/SBRT/IORT (intraoperative) proton beam/neutron hyperthermia treatment, and non-clinical modalities such as SIM/planning/devices/imaging/physics/management

Check eligibility and benefits for eviCore delegation (select service type 30, “Health

Benefit Plan Coverage”).

See specific code list and use the eviCore online request tool.

Members not delegated for eviCore require precert through BCBSAZ for

these services. Use BCBSAZ online request tool

Or call 602-864-4320 / 1-800-232-2345

RADIOLOGY: High-tech imaging (elective/non-emergent, diagnostic imaging provided in locations other than an inpatient hospital), such as CTI, MRI, MRA/PET/NCM, MPI, and some CTAs

Check eligibility and benefits for eviCore delegation (select service type 30, “Health

Benefit Plan Coverage”). See specific code list and use the eviCore

online request tool.

Members not delegated for eviCore require precert through BCBSAZ for

these services. Use BCBSAZ online request tool

Or call 602-864-4320 / 1-800-232-2345 Radiology: High-tech imaging services not included in the eviCore program, including duplex scans, angiography, aortography, transthoracic ECD and ECHO, urethrocystography, and venography

Use BCBSAZ online request tool Or call 602-864-4320 / 1-800-232-2345

Skilled nursing facility (SNF)

Use BCBSAZ online request tool Or call 602-864-4320 / 1-800-232-2345

Sleep studies

Transplants

Transportation: Non-emergency

Standard Precertification List – Effective 10/01/2020 Page 3

MEDICATION PRIOR AUTHORIZATION

SPECIALTY DRUG MANAGEMENT for drugs covered under medical benefits (these are drugs in certain therapeutic classes that must be administered by a healthcare professional) • For eviCore-delegated members (check eviCore delegation via eligibility and benefits inquiry with service type 30, “Health Benefit Plan

Coverage,” selected), use the eviCore online request tool. • For members not in the eviCore program, use the BCBSAZ online request tool or call 602-864-4320 or 1-800-232-2345.

SPECIALTY DRUG MANAGEMENT for drugs covered under pharmacy benefits (these are drugs that can be self-administered) For drugs covered under pharmacy benefits, see the Standard Pharmacy Plans page for specific requirements and contact information for provider assistance and prior authorization requests.

Retail and Mail Order Rx Meds For limitations and prior authorization requirements, see the Standard Pharmacy Plans page. • Use the BCBSAZ online request tool or fax the appropriate request form to 602-864-3126. • If you have questions, call 1-866-325-1794.

1) PPO benefit plans cover services from out-of-network (OON) providers; however, precertification is required for the member to receive in-network level benefits. Requests for OON benefits must be initiated by the referring or treating provider. With precertification for in-network level benefits, the member is still responsible for the balance bill (the difference between the provider’s billed charges and BCBSAZ-allowed amounts).

2) HMO benefit plans do not cover services from out-of-network (OON) providers except for emergency care or when BCBSAZ has precertified OON care because the services cannot be provided in network. Requests for OON services must be initiated by the referring or servicing provider. The member is responsible for any applicable cost share.

Note: Our standard precertification requirements list is used for most of our members; however, it is not used for members with PCP Coordinated Care HMO plans (see pages 4 and 5), Federal Employee Plan® (FEP®) benefit plans (see pages 13 and 14), certain large self-funded employer group plans with customized precertification requirements (see pages 6 through 12), Corporate Health Services (CHS) group plans (contact the group’s TPA), and out-of-area BlueCard® plans (use the BlueCard router tool in the secure provider portal at azblue.com/providers).

eviCore healthcare is a separate, independent company that provides utilization management services to BCBSAZ providers and members.

PCP Coordinated Care HMO Precertification List MEMBER ID PREFIXES: FLH, FQL, NNG, NNJ, PMK, XAH, XHK

PCP Coordinated Care HMO Precertification List – Revised 05/30/2019 Page 4

PCP Coordinated Care HMO plans use a unique precertification requirements list, along with a dedicated provider assistance phone line and a separate online tool for precertification requests and status.

2020 PRECERTIFICATION REQUIREMENTS – for members with PCP Coordinated Care HMO plans

• Use the online referral/precert tool to request precertification or check status. • A PCP-HMO fax form is also available on the secure provider portal: 1-844-263-2272 • Provider assistance: 1-844-807-5106

Notes

Air ambulance (non-emergent) Use PCP HMO online request tool Fax: 1-844-263-2272 / Phone: 1-844-807-5106

Clinical trials

We request prompt notification of participation (from provider or member) to support claim processing for covered services associated with clinical trials.

Dental-related facility services or dental-related services integral to medical services when scheduled as an inpatient admission

Use PCP HMO online request tool Fax: 1-844-263-2272 / Phone: 1-844-807-5106

Durable medical equipment (including repair or replacement of equipment/prosthetics): • Airway clearance devices (chest percussors, vests,

etc.) • Bone growth stimulator • Continuous glucose monitor • Custom/special seating system • Custom wheelchair | power wheelchair/scooter • Dynasplint/JAS (or other mechanical stretching

device)

• Enteral feedings/nutritional formulas • External wearable cardiac defibrillator • Intrapulmonary percussive ventilation • INR monitor, for home • Muscle stimulator • Prosthetics (except breast prosthetics) • Sonic accelerated fracture healing system • Spinal cord stimulator

Epidural/facet injections/radiofrequency ablation

Extended active rehabilitation (EAR) – inpatient rehabilitation services

Genetic testing

Home health – visit limits apply. If home PT/OT/ST is needed, see precertification requirements for outpatient therapies below.

Use PCP HMO online request tool Fax: 1-844-263-2272 / Phone: 1-844-807-5106

Infusion/IV therapy in any setting (hospital outpatient, physician’s office, infusion center, home infusion) covered under medical benefits. Certain drugs may have coverage criteria, including a site-of-service review.

For specific requirements, see the specialty drug information on the next page.

Use PCP HMO online request tool Fax: 1-844-263-2272 / Phone: 1-844-807-5106

Injectable medications that must be administered by a healthcare professional may require precertification and are billed under medical benefits.

Injectable and oral medications that can be self-administered may require prior authorization and are billed under pharmacy benefits.

For specific requirements, see the specialty drug information on the next page.

For medical benefits, call 1-844-807-5106 For pharmacy benefits, call 1-866-325-1794

Inpatient admission • All scheduled admissions require precertification. • Detoxification admissions require precertification. • All emergency admissions, including medical, surgical, maternity, and behavioral

health/substance abuse admissions, require notification within 48 hours of admission.

• Bariatric surgery admissions: The site of service for bariatric surgery must be a Blue Distinction Center for Specialty Care (BDSC). For a current list of Blue Distinction Centers for bariatric surgery, use the BCBS Blue Distinction Facility Search tool.

Use PCP HMO online request tool Fax: 1-844-263-2272 / Phone: 1-844-807-5106

Long-term acute care (LTAC)

Medical foods, metabolic supplements and gastric disorder formula

PCP Coordinated Care HMO Precertification List – Effective 10/01/2020 Page 5

Out-of-network provider See footnote 1

Outpatient surgery – free-standing or hospital-based surgery center: The site of service for bariatric surgery must

be a Blue Distinction Center for Specialty Care (BDSC). For a current list of Blue Distinction Centers for bariatric surgery, use the BCBS

Blue Distinction Facility Search tool.

Use PCP HMO online request tool Fax: 1-844-263-2272 / Phone: 1-844-807-5106

• Abdominoplasty • Bariatric surgery • Blepharoplasty • Cochlear implant • Hysterectomy • Implantable devices, including cochlear implant • Laser treatment (except for retinopathy) • Mammoplasty • Orthognathic services

• Otoplasty • Rhinoplasty/septoplasty • Scar revision • Spinal surgery • Excision/scraping/shaving of lesions • Treatment of varicose veins • Uvulopalatopharyngoplasty (UPP) • Vagus nerve stimulation

Outpatient therapies (PT/OT/ST): Precertification required after 60 combined habilitative/ rehabilitative visits

Use PCP HMO online request tool Fax: 1-844-263-2272 / Phone: 1-844-807-5106

Outpatient XRT (conventional XRT, IMRT and proton beam)

Use PCP HMO online request tool Fax: 1-844-263-2272 / Phone: 1-844-807-5106

Radiology: High-tech imaging (in office, outpatient, ambulatory settings) – MRI, MRA/CT/PET scans/CAT, CTA

Skilled nursing facility (SNF)

Sleep studies and polysomnography

Transplants

Video EEG

MEDICATION PRIOR AUTHORIZATION

Specialty drugs covered under MEDICAL For drugs covered under medical benefits, see the PCP HMO Specialty Medication List for specific requirements. Use the PCP HMO online request tool (in the secure provider portal at “Practice Management > Precertification > BCBSAZ Members-Requests: PCP HMO.” Or fax to: 1-844-263-2272. Phone: 1-844-807-5106

Specialty drugs covered under PHARMACY • For plan names Ascend, Ascend HMO, and Ascend HSA, see the Standard Pharmacy Plans page for specific requirements and contact

information for provider assistance and prior authorization requests. • For plan names EverydayHealth, Portfolio, SimpleHealth, and TrueHealth, see tiered formulary information.

Retail and Mail Order Rx Meds For plan names Ascend, Ascend HMO, and Ascend HSA, see the Standard Pharmacy Plans page for limitations and prior authorization requirements. For plan names EverydayHealth, Portfolio, SimpleHealth, and TrueHealth, see tiered formulary information.

• Fax the appropriate fax request form to 602-864-3126 • If you have questions, call 1-866-325-1794

1) HMO benefit plans do not cover services from out-of-network (OON) providers except for emergent care or in cases where BCBSAZ has

precertified OON care because the services cannot be provided in network. The request for OON services must be initiated by the referring or treating provider. The member is responsible for any applicable cost-share.

• Member’s benefit plan may include out-of-state travel reimbursement for precertified covered services to be provided outside of Arizona.

AMKOR Technology, Inc. Precertification List MEMBER ID PREFIXES: K8Y, K8Z PLAN TYPES: PPO and EPO GROUP NUMBER: 039176

AMKOR Precertification List – 06/01/2020 Page 6

AMKOR Technology contracts with AmeriBen for utilization management, including medical policy.

2020 CUSTOM PRECERTIFICATION REQUIREMENTS – for AMKOR Technology, Inc.

Precertification administered by AmeriBen Medical Management: 1-800-388-3193 Notes

Air ambulance (non-emergency air ambulance transportation)

Call AmeriBen 1-800-388-3193

Dialysis

Durable medical equipment (DME): items over $1,000 and all DME for treatment of obstructive sleep apnea

Genetic testing (excludes amniocentesis and genomic testing)

Home health care

Hospice care

Infusion/injectable medications over $1,500 per infusion/injection, delivered in outpatient setting (outpatient facility, physician’s office, home infusion) and covered under medical benefits

Injectable medications billed under pharmacy benefits may require precertification Call Navitus 1-866-333-2757

Inpatient behavioral health admissions

Call AmeriBen 1-800-388-3193

Inpatient hospital admissions • All elective admissions, except routine maternity deliveries • Maternity stays longer than 48 hours for vaginal delivery and 96 hours for C-section

Inpatient rehabilitation therapy admissions

Mental health and substance abuse: partial hospitalization and intensive outpatient treatment program in excess of 20 visits per calendar year

Oncology: chemotherapy drugs/infusions and radiation treatments

Outpatient rehabilitation services: physical therapy, occupational therapy, and speech therapy visits in excess of 20 per therapy type, per calendar year

Outpatient surgical procedures in a facility setting (excludes pain management injections, office surgeries, screening colonoscopies)

Radiology: outpatient high-tech imaging – MRI/MRA, nuclear cardiology, nuclear medicine, PET scans (excludes services rendered in emergency room setting)

Transplant services: initial evaluation, pre-transplant testing, and surgery

PHARMACY BENEFIT MANAGEMENT

Navitus Health Solutions Navitus

1-866-333-2757 navitus.com

City of Phoenix Precertification List MEMBER ID PREFIX: PXO PLAN TYPES: PPO and EPO Savers Choice GROUP NUMBERS: 040000 (PPO) and 040004 (EPO)

City of Phoenix Precertification List – Effective 10/01/2020 Page 7

2020 CUSTOM PRECERTIFICATION REQUIREMENTS – for City of Phoenix

Arizona provider assistance: 602-864-4320 or 1-800-232-2345 Out-of-state provider assistance: 1-800-676-2583

Notes

Clinical trials

We request prompt notification of participation (from provider or member) to support claim processing for covered services associated with clinical trials.

Extended active rehabilitation (EAR) – inpatient rehabilitation services 602-864-4320 or 1-800-232-2345

Home health care

Infusion/IV therapy in any setting (hospital outpatient, physician’s office, infusion center, home infusion) covered under medical benefits. Certain drugs may have coverage criteria, including a site-of-service review.

Drugs covered under MEDICAL PA requirements: Precert Lookup Tool PA requests: BCBSAZ Members-Online request tool (secure provider portal) or: 602-864-4320 or 1-800-232-2345.

Drugs covered under PHARMACY Call EnvisionRx (see numbers below)

Injectable medications that must be administered by a healthcare professional and are billed under medical benefits may require precertification.

Injectable and oral medications that can be self-administered and are billed under pharmacy benefits may require precertification.

Inpatient admission • All scheduled admissions (including detoxification) require precertification. • All emergent/urgent admissions (including maternity and pre-term labor) require

notification within two calendar days or as soon as reasonably possible following admission.

For benefits and limits, call 602-864-4320 or 1-800-232-2345

Long-term acute care (LTAC) 602-864-4320 or 1-800-232-2345

Out-of-network provider See footnote 1

Outpatient therapies: Physical, occupational and speech – precert required after 60 visits combined

For benefit limits, call 602-864-4320 or 1-800-232-2345

Skilled nursing facility (SNF) 602-864-4320 or 1-800-232-2345

Transplants and stem cell procedures – organ/tissue and blood or bone marrow

PHARMACY BENEFIT MANAGEMENT

EnvisionRx Member Services 1-833-803-4402

EnvisionRx Home Delivery (Mail Order) Pharmacy 1-866-909-5170

EnvisionRx Specialty Pharmacy 1-877-437-9012

1) PPO benefit plans cover services from out-of-network (OON) providers; however, precertification is required for the member to

receive in-network level benefits. The request for OON benefits must be initiated by the referring or treating provider. With precertification for in-network level benefits, the member is still responsible for the balance bill (the difference between the provider’s billed charges and BCBSAZ-allowed amounts).

Northwest Arizona Employee Benefit Trust (NAEBT) Precertification List MEMBER ID PREFIX: NBT PLAN TYPES: EPO and HSA GROUP NUMBER: 037461

NAEBT Precertification List – Revision 06/12/2019 Page 8

NAEBT contracts with American Health Group (AHG) for utilization management, including medical policy.

2020 CUSTOM PRECERTIFICATION REQUIREMENTS – for NAEBT

Precertification administered by American Health Group (AHG): 1-800-847-7605 Notes

Ambulance (fixed wing and helicopter)

Call American Health Group 1-800-847-7605

Clinical trials related to the prevention, detection, or treatment of cancer or other life-threatening disease or condition

Durable medical equipment (DME) over $1,000 purchase price

Home health care

Hospice care services and supplies

Infusion/injectable medications over $1,000 per infusion/injection – covered under medical benefits (not obtained through the prescription drug benefits)

Inpatient pre-admission certification and continued stay reviews (all ages, all diagnoses) • Surgical and non-surgical (excluding routine vaginal or cesarean deliveries) • Inpatient mental health/substance abuse treatment (includes residential treatment

facility services)

Long-term acute care facility (LTAC) – not custodial care

Radiology: outpatient imaging over $1,000 – CT, CT angiography, MRI/MRA, nuclear cardiology, nuclear medicine, PET scans (excludes services rendered in emergency room setting)

Oncology: chemotherapy drugs/infusions and radiation treatments

Skilled nursing facility (SNF) or rehab facility

Sleep study

Surgical procedures over $1,000

Transplants and stem cell procedures – organ/tissue and blood or bone marrow

PHARMACY BENEFIT MANAGEMENT

Navitus Health Solutions Call Navitus Customer Care

1-855-673-6504

OB Sports Golf Management, LLC Precertification List MEMBER ID PREFIX: OBT PLAN TYPES: PPO GROUP NUMBER: 038043

OB Sports Golf Management, LLC Precertification List – Revision 08/06/2019 Page 9

OB Sports Golf Management contracts with AmeriBen for utilization management, including medical policy.

2020 CUSTOM PRECERTIFICATION REQUIREMENTS – for OB Sports Golf Management, LLC

Precertification administered by AmeriBen Medical Management: 1-800-388-3193 Notes

Clinical trials related to prevention, detection, or treatment of cancer or other life-threatening disease or condition Note: Other clinical trials are not covered

Call AmeriBen 1-800-388-3193

Genomic testing

Home health care

Hospice care

Inpatient hospital admissions, except for maternity • Precertification for emergency admissions (subject to extenuating circumstances) must

be obtained within 24 hours of the admission or the first business day following the admission

Inpatient mental health and substance abuse

Outpatient surgical procedures in a facility setting

Skilled nursing facility (SNF)

Transplants

PHARMACY BENEFIT MANAGEMENT

Kroger Prescription Plans Kroger Prescription Plans

1-800-482-1285 kpp-rx.com

Snell & Wilmer Precertification List MEMBER ID PREFIX: SWB, SNK PLAN TYPES: PPO and Indemnity GROUP NUMBER: 030313

Snell & Wilmer Precertification List – Effective 10/01/2020 Page 10

2020 CUSTOM PRECERTIFICATION REQUIREMENTS – for Snell & Wilmer

Arizona provider assistance: 602-864-4320 or 1-800-232-2345 Out-of-state provider assistance: 1-800-676-2583 Notes

Clinical trials

We request prompt notification of participation (from provider or member)

to support claim processing for covered services associated with clinical trials.

Dental-related facility services or dental-related services integral to medical services when scheduled as an inpatient admission

602-864-4320 or 1-800-232-2345 Durable medical equipment (DME)/prosthetics (for rental/purchase price $1,500)

Extended active rehabilitation (EAR) – inpatient rehabilitation services

Home health visits (skilled nurse visits, PT, OT, ST)

Infusion/IV therapy in any setting (hospital outpatient, physician’s office, infusion center, home infusion) covered under medical benefits may require precertification. Certain drugs may have coverage criteria, including a site-of-service review.

Drugs covered under MEDICAL PA requirements: Precert Lookup Tool PA requests: BCBSAZ Members-Online request tool (secure provider portal) or: 602-864-4320 or 1-800-232-2345.

Drugs covered under PHARMACY PA requirements/requests: Standard Pharmacy Plans or call 1-866-325-1794

Injectable medications that must be administered by a healthcare professional may require precertification and are billed under medical benefits.

Injectable and oral medications that can be self-administered may require prior authorization and are billed under pharmacy benefits.

Inpatient admission • All scheduled admissions (including detoxification) require precertification. • All emergent/urgent admissions (including maternity and pre-term labor) require

notification within two calendar days or as soon as reasonably possible following admission.

For benefits and limits, call 602-864-4320 or 1-800-232-2345

Long-term acute care (LTAC) 602-864-4320 or 1-800-232-2345

Out-of-network provider See footnote 1

Outpatient services No precertification required unless otherwise specified.

Skilled nursing facility (SNF) 602-864-4320 or 1-800-232-2345

Transplants and stem cell procedures (major organ and bone marrow) Precertification required if done inpatient.

PHARMACY BENEFIT MANAGEMENT

OptumRx Specialty Pharmacy: For specific requirements, see the Standard Pharmacy Plans page. 1-855-872-5394

Retail and Mail Order Rx Meds: For limitations and prior authorization requirements, see the Standard Pharmacy Plans page 1-866-325-1794

1) PPO benefit plans cover services from out-of-network (OON) providers; however, precertification is required for the member to

receive in-network level benefits. The request for OON benefits must be initiated by the referring or treating provider. With precertification for in-network level benefits, the member is still responsible for the balance bill (the difference between the provider’s billed charges and BCBSAZ-allowed amounts).

State of Arizona Precertification List MEMBER ID PREFIX: SYD, S3Z (Effective 08/01/2020) PLAN TYPES: PPO, EPO, and BluePreferred Care PPO (Effective 08/01/2020) GROUP NUMBER: 030855

State of Arizona Precertification List – Effective 10/01/2020 Page 11

2020 CUSTOM PRECERTIFICATION REQUIREMENTS – for State of Arizona

Arizona provider assistance: 602-864-4320 or 1-800-232-2345 Notes

Ambulance (non-emergency ambulance transportation)

602-864-4320 or 1-800-232-2345

Autism spectrum disorder treatment Bariatric surgery Cancer clinical trials Cochlear implants and hearing aids Dental (accidental dental services, dental confinement) Dialysis (end-stage renal disease services) Durable medical equipment (foot orthotic devices and inserts; repair or replacement of equipment and prosthetics) Epidural and facet injections Extended active rehabilitation Home health care Hospital services that require precertification:

• All elective inpatient admissions • Maternity (>48 hours for a normal delivery or >96 hours for cesarean delivery) • Neonatal intensive care unit (NICU) admission • Observation status exceeding 23 hours • Emergent/urgent admissions require both notification and precertification by

the end of the second scheduled business day after the admission.

For benefits and limits, call 602-864-4320 or 1-800-232-2345

Infusion/IV therapy in any setting (hospital outpatient, physician’s office, infusion center, home infusion) covered under medical benefits. Certain drugs may have coverage criteria, including a site-of-service review.

Drugs covered under MEDICAL PA requirements: Precert Lookup Tool PA requests: BCBSAZ Members-Online request tool (secure provider portal) or: 602-864-4320 or 1-800-232-2345.

Drugs covered under PHARMACY Call 1-888-648-6769

Injectable medications that must be administered by a healthcare professional may require precertification and are billed under medical benefits.

Injectable and oral medications that can be self-administered may require prior authorization and are billed under pharmacy benefits. Long-term acute care (LTAC)

602-864-4320 or 1-800-232-2345 Medical foods, metabolic supplements and gastric disorder formula Orthognathic treatment or surgery Out-of-network provider (for services not available through an in-network provider) See footnote 1 Outpatient ambulatory: Cardiac testing/angiography/sleep testing (sleep studies and polysomnography)/video EEG/biofeedback

602-864-4320 or 1-800-232-2345

Radiation therapy – IMRT/proton beam therapy Radiofrequency ablation Radiology: High-tech imaging – CAT/CT/MRI, MRA/PET scans/BEAM (brain electrical activity mapping) – outpatient and ambulatory Services that have a potential for a cosmetic component, including but not limited to: blepharoplasty (upper lid), breast reduction, breast reconstruction, ligation (vein stripping), and sclerotherapy Skilled nursing facility (SNF) Transplants

PHARMACY BENEFIT MANAGEMENT

MedImpact 1-888-648-6769

PPO benefit plans cover services from out-of-network (OON) providers; however, precertification is required for the member to receive in-network level benefits. The request for OON benefits must be initiated by the referring or treating provider. With precertification for in-network level benefits, the member is still responsible for the balance bill (between the provider’s billed charges and BCBSAZ-allowed amounts).

Teamsters Precertification List MEMBER ID PREFIX: TYW PLAN TYPE: PPO GROUP NUMBERS: 031843 (Actives) and 031844 (Retirees)

Teamsters Precertification List – Effective 10/01/2020 Page 12

2020 CUSTOM PRECERTIFICATION REQUIREMENTS – for Teamsters

Arizona provider assistance: 602-864-4320 or 1-800-232-2345 Out-of-state provider precertification requests: 1-800-676-2583

Notes

Behavioral and mental healthcare See footnote 1

Clinical trials Benefits are available for cancer clinical trials for active members with plan coverage.

Dental-related facility services or dental-related services integral to medical services when scheduled as an inpatient admission Note: Dental implants must be precertified by the dental claims administrator

For details, call Aetna Dental member services at 1-877-238-6200

Extended active rehabilitation (EAR) – inpatient rehabilitation services 602-864-4320 or 1-800-232-2345

Home health care and private duty nursing

Infusion/IV therapy in any setting (hospital outpatient, physician’s office, infusion center, home infusion) covered under medical benefits. Certain drugs may have coverage criteria, including a site-of-service review.

Drugs covered under MEDICAL PA requirements: Precert Lookup Tool PA requests: BCBSAZ Members-Online request tool (secure provider portal) or: 602-864-4320 or 1-800-232-2345.

Drugs covered under PHARMACY Call 1-800-711-3814

Injectable medications that must be administered by a healthcare professional may require precertification and are billed under medical benefits.

Injectable and oral medications that can be self-administered may require prior authorization and are billed under pharmacy benefits.

Inpatient admission • All scheduled admissions (including detoxification) require precertification. • All emergent/urgent admissions (including maternity and pre-term labor) require

notification within 48 hours of admission. Note: For pregnant women, precertification is only required for hospital stays that last or are expected to last longer than 48 hours for vaginal delivery or 96 hours for a C-section.

602-864-4320 or 1-800-232-2345

Long-term acute care (LTAC)

Out-of-network provider See footnote 2

Outpatient services do not require precertification unless otherwise specified 602-864-4320 or 1-800-232-2345

Skilled nursing facility (SNF)

PHARMACY BENEFIT MANAGEMENT

Specialty Drugs: Express Scripts 1-800-711-3814

Retail and Mail Order Rx Medications: Express Scripts

1) The behavioral services administrator (BSA) is the exclusive provider to precertify and manage behavioral and mental healthcare

benefits. For outpatient behavioral health services, members must coordinate care through the BSA by contacting the BSA prior to the receipt of care, to discuss the most appropriate provider and course of treatment. Call the BSA – Beacon Health Options (formerly known as Value Options) – at 1-855-884-7080 to precertify or coordinate services.

2) PPO benefit plans cover services from out-of-network (OON) providers; however, precertification is required for the member to

receive in-network level benefits. The request for OON benefits must be initiated by the referring or treating provider. With precertification for in-network level benefits, the member is still responsible for the balance bill (the difference between the provider’s billed charges and BCBSAZ-allowed amounts).

Federal Employee Program® (FEP®) Precertification/Prior Approval List MEMBER ID PREFIX: R SERVICE BENEFIT PLAN

FEP Precertification/Prior Approval List – Revision 01/01/2020 Page 13

2020 PRECERTIFICATION and PRIOR APPROVAL REQUIREMENTS for FEP

FEP provider assistance: 602-864-4102 or 1-800-345-7562 Weekends and holidays: 602-864-4320 or 1-800-232-2345

Benefit Plan Names:

Standard and Basic Options

FEP Blue Focus

Air ambulance transport (for non-emergency care) 602-864-4102 or 1-800-345-7562

Applied behavior analysis (ABA) Prior approval required for ABA and all related services, including assessments, evaluations, and treatments.

Cardiac rehabilitation N/A Clinical trials (for certain blood or marrow stem cell transplants) See footnote 1 Cochlear implants N/A Dental-related facility services or dental-related services integral to medical services when scheduled as an inpatient admission 602-864-4102 or 1-800-345-7562 Detoxification (scheduled IP admissions)

Durable medical equipment (DME) – specialty durable medical equipment (rental or purchase), including:

Specialty hospital beds Deluxe wheelchairs, power wheelchairs, mobility devices, and related supplies

N/A

Extended active rehabilitation (EAR) – inpatient rehabilitation services 602-864-4102 or 1-800-345-7562 Emergency admission – notify FEP provider assistance for precertification within two

business days following the day of ER admission (even if the patient has been discharged) Gender reassignment surgery See footnote 2 Gene therapy and cellular immunotherapy (examples include CAR-T and T-cell receptor therapy) 602-864-4102 or 1-800-345-7562 Hospice Inpatient admission – scheduled IP admissions, including medical, surgical, psychiatric, and residential treatment center (RTC) admissions Maternity admission – only for stays longer than 48 hours post vaginal delivery and

longer than 96 hours post C-section Newborn stays – only when requiring definitive treatment during or after the

mother’s confinement

For all scheduled admissions call: 602-864-4102 or 1-800-345-7562

Prior to RTC admission, approval is required and member must be enrolled in case management.

• Bariatric surgery See footnote 3 Laboratory – BRCA testing for BRCA1 or BRCA2 mutations See footnote 4 Laboratory – genetic testing for the diagnosis and/or management of an existing medical condition 602-864-4102 or 1-800-345-7562 Long-term acute care (LTAC) Oral medical foods (pharmacy benefit only) See footnote 5 Outpatient intensity modulated radiation therapy (IMRT) for all services except treatment of breast, prostrate, anal, neck, and head cancer (brain cancer is not considered a form of head or neck cancer)

602-864-4102 or 1-800-345-7562 Outpatient surgery for the following procedures: Surgical correction of congenital anomalies Surgery needed to correct accidental injuries to jaws, cheeks, lips, tongue, roof and

floor of mouth Gender reassignment Morbid obesity See footnote 3 Orthognathic surgery procedures, bone grafts, osteotomies, and surgical

management of the temporomandibular joint (TMJ) Orthopedic procedures: hip, knee, ankle, spine, shoulder, and all orthopedic

procedures using computer-assisted musculoskeletal surgical navigation Reconstructive surgery for conditions other than breast cancer Rhinoplasty Septoplasty Varicose vein treatment

N/A

FEP Precertification/Prior Approval List – Revision 01/01/2020 Page 14

Prosthetic devices (external) N/A Pulmonary rehabilitation N/A Radiology: High-tech imaging, including MRI, CT, PET N/A Residential Treatment Center (RTC) outpatient care N/A Skilled nursing facility (SNF) – 30-day annual maximum limit. This benefit is only available for members with the Standard Option who are not enrolled in Medicare Part A. When Medicare Part A is not the primary payer, there is no SNF benefit under the Basic Option or FEP Blue Focus plans (when Medicare is primary and has made a payment, there are limited secondary benefits and precertification is not required).

Not all plans have a skilled nursing facility benefit. Specific requirements must be met prior to admission. See 2020 plan-specific brochures and FEP Medical Policy info.

Sleep studies performed in a location other than the home N/A Transplants, stem cell procedures (may include site-of-service requirements), and certain related services/expenses (e.g., travel) See footnote 6

PHARMACY BENEFIT MANAGEMENT

Formulary and prior approval lists are available on the FEP website. fepblue.org/benefit-plans/coverage/pharmacy

Specialty drugs: AllianceRx Walgreens Prime (hours: 7:00 a.m. – 9:00 p.m. Eastern Time, Monday – Friday; 8:00 a.m. – 6:30 p.m. Eastern Time, Saturday & Sunday)

1-888-346-3731

Pharmacy and mail service prescription drugs: CVS Caremark (hours: 7:00 a.m. – 9:00 p.m. Eastern Time, Monday – Friday) 1-800-624-5060

1) For clinical trials for certain blood or marrow stem cell transplants, call the FEP organ transplant line at 602-864-4051. For the list of

conditions covered only in clinical trials, refer to the 2020 plan-specific brochures on the fepblue.org website.

2) Prior to surgical treatment of gender dysphoria, the provider must submit a treatment plan including all surgeries planned and the estimated date each will be performed. A new prior approval must be obtained if the treatment plan is approved and the provider later modifies the plan (including changes to the procedures to be performed or the anticipated dates for the procedures). If the surgical procedure requires an inpatient admission, inpatient care must also be precertified.

3) For Blue Focus Plan members only, the site of service for bariatric surgery must be a Blue Distinction Center for Specialty Care (BDSC).

For a current list of Blue Distinction Centers for bariatric surgery, use the BCBS Blue Distinction Facility Search tool.

4) Prior approval is required for BRCA testing and testing (preventive and diagnostic) for large genomic rearrangements in BRCA1 and BRCA2 genes. Patients must receive genetic counseling and evaluation services before preventive BRCA testing.

5) Specialized nutritional formulas for children up to age 22 to treat inborn errors of amino acid metabolism or medical foods, as defined by the U.S. Food and Drug Administration, that are administered orally and that provide the sole source (100%) of nutrition, for up to one year following the date of the initial prescription or physician order for the medical food (e.g., Neocate) in formula form only. Call CVS Caremark at 1-800-624-5060.

6) See plan-specific brochures for detailed information on transplant benefits and requirements, including site of service.

Certain blood or marrow stem cell transplants must be performed in a facility with a transplant program accredited by the Foundation for the Accreditation of Cellular Therapy (FACT), or in a facility designated as a Blue Distinction Center for Transplants (BDCT), or as a cancer research facility.

Certain transplant procedures must be performed at a FACT-accredited facility. Call the FEP transplant coordinator at 602-864-4051.

Certain organ transplant procedures must be performed in a facility with a Medicare-approved transplant program for the type of transplant anticipated.