ERS HealthSelect of Texas® & Consumer Directed HealthSelectSM Out-Of-State Prior Authorization & Referral Requirements List – 9/1/2020 Form

A Division of HealthCare Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 1

1. Inpatient Facility Admissions Including Transfers (In-Network)
   • 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 Inpatient Facility Admissions Including Transfers (In- Network) For Mental Health(MH) Prior Authorization Services Inpatient, Residential, and Partial Day Stays
   • Neurobiological Disorders
   • Substance Abuse Disorders
   • Serious Mental Illness Prior Authorization Requires Medical Management Review. No referral required for any service by network providers. For Out-of-Network referrals see #6
2. Obstetrical care Maternity notification. No referral required for any service by network providers. For Out-of-Network referrals see # 6. HealthSelect of Texas® & Consumer Directed HealthSelectSM Out-of-State Plan Participants PRIOR AUTHORIZATION & REFERRAL REQUIREMENTS LIST Effective September 1, 2020 • Participants utilize Blue Card PPO network. Participants do not have to designate a Primary Care Physician (PCP) and in-network referrals are not required. • Out-of-Network Services 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 REQUIREMENTS through eviCore Outpatient Only
3. Molecular and genomic testing
4. Radiation oncology for all outpatient and office services
5. Advanced Radiology Imaging
6. Sleep Studies and Sleep Durable Medical Equipment (DME) (No prior authorization required for the resupply of Sleep DME supplies effective 8/1/2018 Requires contacting eviCore for Prior Authorization at evicore.com or 855-252-117 Note: For specific codes that apply, please visit https://www.evicore.com/healthplan/bcbs on eviCore.com or call toll-free 855-252-1117. If Medicare is Primary, no referrals or prior authorizations are required. • Updated 08/20/2020 PRIOR AUTHORIZATION & REFERRAL REQUIREMENTS through Availity® Authorization & Referrals/Medical Management PRIOR AUTHORIZATION through Availity Authorization & Referrals/Medical Management REFERRAL through Availity Authorization & Referrals/Medical Management

A Division of HealthCare Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 2 HealthSelect of Texas & Consumer Directed HealthSelect Out-of-State Plan Participants PRIOR AUTHORIZATION & REFERRAL REQUIREMENTS List Effective Effective September 1, 2020 • Participants utilize Blue Card PPO network. Participants do not have to designate a PCP and in-network referrals are not required. • Out-of-Network Services 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

3. Outpatient - Private duty nursing - Home infusion therapy (Not covered – Non-Network) - Home health (Exception-Home Dialysis no prior authorization required) - Select durable medical equipment (DME) greater than $1,000 (including but not limited to prosthetic devices) - Non Emergent Air and Ground Ambulance - Congenital Heart Disease Services - Reconstructive Procedures (including but not limited to breast reduction surgery) - Transplant Services - Outpatient Surgery - Facility setting (Including but not limited to: diagnostic catheterization, electrophysiology implant and sleep apnea.) . - Orthognathic Surgery - Specialty Drugs (See List for Qualifying Drugs) Prior Authorization - Outpatient Mental Health (MH) Services Prior Authorization 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 No referral required for any service by network providers. Not covered under the HealthSelect Out-of-State Plan. Not covered under the HealthSelect Out-of- State Plan. No referral required for any service by network providers.
4. Out-of-Network Out-of-network services require Medical Management Review for certain services requiring Prior Authorization. Emergency services are an exception to this requirement. Out-of-network services require Medical Management Review for certain services requiring Prior Authorization. Emergency services are an exception to this requirement. Updated 08/20/2020 • If Medicare is Primary, no referrals or prior authorizations are required.
5. Bariatric Surgery
6. In-Network Refer to specific service on this Prior Authorization list. Prior Authorization Requires Medical Management Review. First visits 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. PRIOR AUTHORIZATION & REFERRAL REQUIREMENTS through Availity® Authorization & Referrals/Medical Management PRIOR AUTHORIZATION through Availity Authorization & Referrals/Medical Management REFERRAL through Availity Authorization & Referrals/Medical Management