ERS Consumer Directed HealthSelectSM (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 1 Consumer Directed HealthSelectSM (In -Texas) PRIOR AUTHORIZATION & REFERRAL REQUIREMENTS LIST Effective September 1, 2020 PRIOR AUTHORIZATION& REFERRALREQUIREMENTS PRIOR AUTHORIZATION REFERRAL

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 Prior Authorization Requires Medical Management. 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 participants will be held harmless in all instances. 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. • Consumer Directed HealthSelect is an open access plan utilizing the Blue Essentials SM provider 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. • If Medicare is Primary, no referrals or Prior Authorizations are required. • Use Availity® Authorization & Referrals to prior authorize and set up referrals when necessary. Updated 08-20-2020
3. Outpatient - Private duty nursing - Home infusion therapy (Out-of-Network/Out-of-Plan not covered) - Home health (Exception: Home Dialysis no Prior Authorization needed) - 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) - Molecular and Genomic Testing - Radiation Oncology for all outpatient and office services - Advanced Radiology Imaging - Sleep Studies and Sleep Durable Medical Equipment (DME) Prior Authorization Requires Medical Management Review. First 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 participants will be held harmless in all instances. No referral required for any service by network providers. through Availity® Authorizations & Referrals / Medical Management through Availity Authorizations & Referrals / Medical Management through Availity Authorizations & Referrals / Medical Management

2 Consumer Directed HealthSelect (In-Texas) PRIOR AUTHORIZATION & REFERRAL REQUIREMENTS LIST Effective September 1, 2020 PRIOR AUTHORIZATION& REFERRAL REQUIREMENTS PRIOR AUTHORIZATION REFERRAL

4. Bariatric Surgery Not covered under the Consumer Directed HealthSelect benefit plan. Not covered under the Consumer Directed HealthSelect benefit plan.
5. In-Network Refer to specific service on this Prior Authorization list. No referral required for any service by network providers.
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.
   Emergency services are an exception to this requirement. • Consumer Directed HealthSelect is an open access plan utilizing the Blue Essentials provider 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. • If Medicare is Primary, no referrals or Prior Authorizations are required. • Use Availity® Authorization & Referrals to prior authorize and set up referrals when necessary. Updated 08-20-2020 Mental Health (MH) Prior Authorization Services Inpatient, Residential, and Partial Day Stays. Note: Effective 9/1/2020, Mental Health Services Are Managed by BCBSTX Medical Management
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 Out-of-network services always require Medical Management Review and referral when participant wants to use their in-network benefits. through Availity Authorizations & Referrals / Medical Management through Availity Authorizations & Referrals / Medical Management through Availity Authorizations & Referrals / Medical Management 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 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.