ERS HealthSelect of Texas® (In-Texas) Prior Authorization & Referral Requirements List – 9/1/2020 Form

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association HealthSelect of Texas® (In-Texas) PRIOR AUTHORIZATION & REFERRAL REQUIREMENTS LIST Effective September 1, 2020 • • Out-of-network services that require Prior Authorization always require Medical Management Review. If no Prior Authorization is obtained for out-of-network services requiring Prior Authorization (See #6 below), benefits may be reduced or denied. Emergency Services are an exception to this requirement. • HealthSelect of Texas requires referrals from a Primary Care Physician (PCP) using the Blue Essentials℠ provider network for network benefits. Prior Authorization requires Medical Management Review. PRIOR AUTHORIZATION & REFERRAL REQUIREMENTS through Availity® Authorizations & Referrals/Medical Management PRIOR AUTHORIZATION through Availity Authorizations & Referrals/ Medical Management REFERRAL through Availity Authorizations & Referrals/ Medical Management 1. Inpatient Facility Admissions Including Transfers (In- Network) including but not limited to: - Hospital - Rehab - Long Term Acute Care / Sub-acute Inpatient admissions - Inpatient hospice and rehabilitation - Skilled nursing (facility-based) - Congenital Heart Disease Services - Reconstructive Procedures (including but not limited to breast reduction surgery - Transplant Services - Orthognathic Surgery Prior Authorization Requires Medical Management Review. Any network service where Prior
Authorization is not obtained by the provider before the service is rendered, the service will be denied by BCBSTX and the participant will be held harmless in all instances. Referral required from PCP to Specialist for network services .

2. Obstetrical Care Maternity notification For Out-of- Network referrals See #6 • Participants have direct access to care with out-of-network providers at the out-of-network benefit level and no referral is required. Prior Authorization may still be required. (See # 6 below regarding out-of network referrals). • If Medicare is Primary, no referrals or Prior Authorizations are required. • Use Availity® Authorization & Referrals to prior authorize and set up referrals when necessary. 1 Updated 08-20-2020 Prior Authorization Requires Medical Management Review. Initial visits for physical therapy, speech therapy, and occupational therapy do not require a Prior Authorization. All subsequent visits will require an approved Prior Authorization to include a treatment plan. Any network service where Prior Authorization is not obtained by the provider before the service is rendered, the service will be denied by BCBSTX and the participant will be held harmless in all instances. Referral required from PCP to Specialists for network services. Exceptions:  
3. Outpatient Outpatient - Private Private duty duty nursing nursing - Home Home infusion infusion therapy therapy (Out-of (Out-of-Network/Out-of -Network/Out-of-Plan -Plan tnot covered) covered) - Home Home health health (Exception:Home (Exception:Home Dialysis Dialysis - - no Prior Authorization is required) - Select Select durable durable medical medical equipment equipment (DME) (DME) greater greater than than $1,000 $1,000 (including (including but but not not limited limited to to prosthetic prosthetic devices) devices) - Non-Emergent Non-Emergent Air Air and and Ground Ground Ambulance Ambulance - Congenital Congenital Heart Heart Disease Disease Services Services - Reconstructive Procedures (including but not limited to breast    Physical therapy, occupational therapy and speech therapy do not require a referral, but do require Prior Authorization for subsequent visits. Chiropractor OB-Gyn Retail health Therapeutic Optometrist or Ophthalmologist (Routine or diagnostic exams) Urgent Care Providers Mental Health Counseling Doc on Demand  MDLIVE    Outpatient Surgery- Facility setting (Including but not limited to:diagnostic catheterization, electrophysiology implant and sleep apnea). Orthognathic Surgery Specialty Specialty Drugs (See List for Qualifying Drugs) Physical Therapy/Speech Therapy/Occupational Therapy Molecular and Genomic Testing Radiation Oncology for all outpatient and office services Advanced Radiology Imaging Sleep Studies and Sleep Durable Medical Equipment (DME) - - - - - - - -

HealthSelect of Texas (In-Texas) PRIOR AUTHORIZATION & REFERRAL REQUIREMENTS LIST Effective September 1, 2020 • HealthSelect of Texas requires referrals from a PCP using the Blue Essentials℠ provider network for network benefits. • Out-of-network services that require Prior Authorization always require Medical Management Review. If no Prior Authorization is obtained for out-of-network Services requiring Prior Authorization (See #6 below), benefits may be reduced or denied. Emergency Services are an exception to this requirement. • Prior Authorization requires Medical Management Review. PRIOR AUTHORIZATION & REFERRAL REQUIREMENTS PRIOR AUTHORIZATION REFERRAL

4. Bariatric Surgery (Out-of-Network/Out-of-Plan not covered) (Only covered at Centers of Excellence by In-Network Physicians) Prior Authorization Requires Medical Management Review. Any network service where Prior Authorization is not obtained by the provider before the service is rendered, the service will be denied by BCBSTX and the participant will be held harmless in all instances. Referral required from PCP for Specialist for network services.
5. In-Network Refer to specific service on this Prior Authorization list Any network service where Prior Authorization is not obtained by the provider before the service is rendered, the service will be denied by BCBSTX and the participant will be held harmless in all instances. Referral required from PCP to Specialists for network services.
6. Out-of-Network Out-of-network services may require Medical Management review for certain services requiring Prior Authorization. Emergency services are an exception to this requirement. Out-of-network services may require Medical Management review for certain services requiring Prior Authorization. Participants have direct access to care with out-of-network providers at the out-of-network benefit level and no referral is required. Prior Authorization may still be required Emergency services are an exception to this requirement. • If Medicare is Primary, no referrals or Prior Authorizations are required. • Use Availity® Authorization & Referrals to prior authorize and set up referrals when necessary. Participants have direct access to care with out-of-network providers at the out-of-network benefit level and no referral is required. Prior Authorization may still be required. (See # 6 below regarding out-of network referrals). • 2 Updated 08-20-2020 Mental Health (MH) Prior Authorization Services Inpatient, Residential, and Partial Day Stays. PRIOR AUTHORIZATION & REFERRAL REQUIREMENTS PRIOR AUTHORIZATION REFERRAL
7. Inpatient Facility Admissions Including Transfers (In- Network)
   • Neurobiological Disorders
   • Substance Abuse Disorders
   • Serious Mental Illness
8. Outpatient Mental Health Services
   • (Including Intensive Outpatient Program (IOP) for MH and SUD; Repetitive Transcranial Magnetic Stimulation (rTMS); Electro- Convulsive Therapy (ECT); and Applied Behavioral Analysis (ABA), for Autism Spectrum Prior authorization is required.
     Any network service where Prior Authorization is not obtained by the provider before the service is rendered, the service will be denied and the participant will be held harmless in all instances. PCP referral not required. through Availity Authorizations & Referrals/ Medical Management through Availity Authorizations & Referrals/Medical Management through Availity Authorizations & Referrals/ Medical Management through Availity Authorizations & Referrals/Medical Management through Availity Authorizations & Referrals / Medical Management Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX. BCBSTX makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by the vendor, you should contact the vendor directly. Note: Effective 9/1/2020, Mental Health Services Are Managed by BCBSTX Medical Management Out-of-network services always require Medical Management Review and referral when participant wants to use their in-network benefits.