Tpa Co Admin.Pdf Form

AZ Blue/TPA Co-Administered Plans: Medical Policy and Prior Authorization 02-2025 Page 1

AZ Blue/TPA Co-Administered Group Plans Medical Policies and Prior Authorization

The groups listed below use a third-party utilization management (UM) administrator to determine medical policy and prior authorization requirements. Please contact the group’s UM administrator directly for medical policy information and prior authorization requests.

EMPLOYER GROUP UTILIZATION MANAGEMENT MEMBER ID PREFIX PRIOR AUTH REQUIREMENTS Amkor Technology, Inc. Group 039176
AmeriBen 1-800-388-3193 PBM: Navitus 1-866-333-2757 K8Y, K8Z Page 2 Microchip Technologies Group 045928 AmeriBen 1-866-879-6128 PBM: Optum Direct
1-800-207-2568 MKQ Page 3 Northwest Arizona Employee Benefit Trust (NAEBT) Group 037461 American Health Group (AHG) 1-800-847-7605 PBM: Navitus 1-855-673-6504 NBT Page 4 Pioneer Title Holding Company, Inc. Group 044410 AmeriBen 1-800-388-3193 PBM: Prime Therapeutics
1-800-424-0472
Specialty Rx 1-877-300-6202 PTP Pages 5-6

Prior authorization requirements are summarized for each group on the following pages.

Prior authorization is not a guarantee of payment: Prior authorization helps determine a member’s eligibility for a requested procedure or service before the service is rendered. Prior authorization approval decisions are based on information provided during the request process and typically requires medical records. Even if a service is authorized, the claim for the rendered service is reviewed and processed according to specific benefit plan coverage, including any applicable limitations, exclusions, maximums, and waivers. Although prior authorization may not be required for a particular service, any claim may still be subject to review for medical necessity.
Penalties: If a required prior authorization is not obtained prior to service, a penalty is applied to the contracted servicing provider or facility. If an out-of-network provider is used, the penalty is applied to the member.

Amkor Technology, Inc. Prior Authorization List MEMBER ID PREFIXES: K8Y, K8Z PLAN TYPES: PPO and EPO GROUP NUMBER: 039176 Amkor Prior Authorization Requirements – Revised 01/01/2021 Page 2

Amkor contracts with AmeriBen for utilization management, including medical policy: 1-800- 388-3193 The PBM is Navitus: navitus.com or 1-866-333-2757

CUSTOM PRIOR AUTHORIZATION REQUIREMENTS for AMKOR Technology, Inc. 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 prior authorization 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 use disorder: 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 only Transplant services: initial evaluation, pre-transplant testing, and surgery PHARMACY BENEFIT MANAGEMENT Navitus Health Solutions 1-866-333-2757 navitus.com

Microchip Technologies Prior Authorization List MEMBER ID PREFIX: MKQ PLAN TYPES: EPO, PPO, HDHP GROUP NUMBER: 045928 Microchip Prior Authorization Requirements – 01/01/2025 Page 3

Microchip contracts with AmeriBen for utilization management, including medical policy: 1-866- 879-6128 The PBM is Optum Direct: 1-800-207-2568

CUSTOM PRIOR AUTHORIZATION REQUIREMENTS for Microchip Technologies Air ambulance (non-emergency air ambulance transportation) Call AmeriBen 1-866-879-6128 Clinical trials related to prevention, detection, or treatment of cancer or other life- threatening disease or condition (plan does not cover other clinical trials) Dialysis Durable medical equipment (DME) in excess of $3,000 (purchase/rental price), including orthotics/prosthetics Genetic/genomic testing (excludes amniocentesis) Home health care (excluding home infusion services) Inpatient behavioral health/substance use disorder admissions (includes residential treatment facility services) Inpatient hospital admissions and continued stays • All elective admissions, except routine maternity deliveries • Maternity stays longer than 48 hours for vaginal delivery and 96 hours for C- section Inpatient rehabilitation admissions: Skilled nursing facilities and long-term care facilities (not custodial care) Mental health and substance use disorder: Partial hospitalization and intensive outpatient program in excess of 18 visits per calendar year per therapy type Oncology: chemotherapy drugs/infusions and radiation treatments for oncology diagnoses Outpatient rehabilitation services: physical therapy, occupational therapy, and speech therapy visits in excess of 18 per therapy type, per calendar year Outpatient advanced radiology (excludes services rendered in an emergency room setting): Coronary CT angiography, nuclear cardiology, nuclear medicine (including SPECT scans), PET scans Specialty Infusion/injectable medications over $3,000 per infusion/injection, covered under medical benefits (not obtained through pharmacy benefits) and delivered in outpatient setting (outpatient facility, physician’s office, home infusion) Specialty medications billed under pharmacy benefits may require prior authorization Call Optum Direct 1-800-207-2568 Surgical procedures in an inpatient or outpatient facility setting (excludes office surgeries, screening and diagnostic colonoscopies, elective sterilization procedures, and intra-articular hyaluronic acid injections) Call AmeriBen 1-866-879-6128 Transplant (other than cornea): Initial evaluation, pre-transplant testing, and surgery PHARMACY BENEFIT MANAGEMENT Optum Direct 1-800-207-2568

Northwest Arizona Employee Benefit Trust (NAEBT) Prior Auth List MEMBER ID PREFIX: NBT PLAN TYPES: EPO and HSA GROUP NUMBER: 037461 NAEBT Prior Authorization Requirements – Revised 03/31/2023 Page 4

NAEBT contracts with American Health Group (AHG) for utilization management, including medical policy: 1-800-847-7605 The PBM is Navitus: navitus.com or 1-855-673-6504

CUSTOM PRIOR AUTHORIZATION REQUIREMENTS for NAEBT 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 Genetic testing for treatment
Note: Diagnostic genetic testing is an excluded benefit, except for mandated testing 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 use disorder 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 1-855-673-6504 navitus.com

Pioneer Title Holding Company Prior Auth List MEMBER ID PREFIX: PTP PLAN TYPE: PPO GROUP NUMBER: 044410 Pioneer Title Holding Company Prior Authorization Requirements – Revised 02/04/2025 Page 5

Pioneer Title contracts with AmeriBen for utilization management, including medical policy:
1-800-388-3193 The PBM is Prime Therapeutics (Prime): primetherapeutics.com/providers-and-physicians or
1-800-424-0472 | Specialty Rx 1-877-300-6202

CUSTOM PRIOR AUTHORIZATION REQUIREMENTS for Pioneer Title Holding Company, Inc. Adoptive cell therapy Call AmeriBen 1-800-388-3193 Air ambulance (non-emergency) Clinical trial conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition Note: This plan does not cover clinical trials related to other diseases or conditions (check the member benefit book for further description and limitations) Dialysis Durable medical equipment (DME): Items in excess of $3,000 (purchase/rental price) Genetic/genomic testing (excludes amniocentesis) Home health care services (excludes home infusion services) Imaging, high-tech outpatient (excludes services rendered in an emergency room setting): • Computed tomographic (CT) studies • Coronary CT angiography • MRI/MRA • Nuclear cardiology • Nuclear medicine (including SPECT scans) • PET scans Infusion/injectable specialty medications over $3,000 per infusion/injection, delivered in outpatient setting (outpatient facility, physician’s office, home infusion) and covered under medical benefits (not pharmacy benefits) Injectable and specialty medications billed under pharmacy benefits may require prior authorization Call Prime Therapeutics
1-800-424-0472 Specialty Rx 1-877-300-6202
Inpatient hospital pre-admission and continued stay reviews (all ages, all diagnoses) • Long-term acute care facility (LTAC), not custodial care • Skilled nursing facility (SNF) and rehabilitation facility • Inpatient mental health/substance use disorder treatment (includes residential treatment facility services) • All surgical and non-surgical admissions (excluding routine vaginal or cesarian deliveries) Note: The attending physician does not have to obtain prior authorization for a maternity stay of 48 hours or less for a vaginal delivery or 96 hours or less for a cesarean delivery.

Call AmeriBen 1-800-388-3193

Mental health and substance use disorder: Partial hospitalization and intensive outpatient treatment program in excess of 18 visits per calendar year per therapy type Oncology: Chemotherapy drugs/infusions and radiation treatments

Pioneer Title Holding Company Prior Authorization Requirements – Revised 02/04/2025 Page 6 Orthotics/prosthetics in excess of $3,000 (purchase/rental price)

Call AmeriBen 1-800-388-3193 Outpatient rehabilitation services: Physical therapy, occupational therapy, and speech therapy visits in excess of 18 visits per therapy type, per calendar year Surgical procedures (inpatient and outpatient) Exception: Prior authorization is not required for the following surgical procedures. • Office surgeries • All colonoscopies and sigmoidoscopies (screening and diagnostic) • Elective female sterilization procedures • Intra-articular hyaluronic acid injections Transplant (other than cornea), including but not limited to, kidney, liver, heart, lung, pancreas, and bone marrow replacement to stem cell transfer after high-dose chemotherapy PHARMACY BENEFIT MANAGEMENT Prime Therapeutics (Prime) 1-800-424-0472 Specialty Rx 1-877-300-6202
primetherapeutics.com/providers- and-physicians