Connecticut Prior Authorization List Form

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan. CarelonRx, Inc. is an independent company providing pharmacy benefit management services on behalf of the health plan. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. CTBCBS-CM-094370-25 | October 2025 Connecticut Precertification/Prior Authorization List

Connecticut | Anthem Blue Cross and Blue Shield | Commercial

For HMO type health plans: Under our HMO plans and products:  It is the participating physician’s or care provider’s responsibility to contact our Utilization Management Department at 800-238-2227 or another number indicated below for specific services, to obtain precertification/prior authorization.  The request must come from the care provider or facility rendering the service, not the referring physician, except as described below for specific services. If precertification/prior authorization is not obtained, the claim payment may be reduced or deemed ineligible for reimbursement by the plan and the member must be held harmless.

For PPO type health plans — under our PPO plans and products:  Services provided by a network care provider: The care provider is responsible for precertification/prior authorization services provided by a BlueCard® or a nonparticipating care provider. The member is responsible for precertification/prior authorization. The member is financially responsible for services and/or settings that are not covered under the certificate based on an adverse determination of medical necessity or experimental or investigational services.  Contact our Utilization Management Department to obtain precertification at: 800-238-2227 or another number indicated below for specific services.

The precertification number is listed on the back of our member’s ID card.

UM decisions — appropriateness of care and services As part of our goal to improve the health of the members we serve, we are committed to promoting appropriate utilization of medical services. Please note that people who make UM decisions do not receive compensation or incentives to deny care. This also applies to people who supervise them, including management, medical directors, utilization management managers,

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and licensed staff. UM decisions are based only on appropriateness of care and services and the existence of coverage. The plan does not specifically reward for denial of services, or offer incentives to encourage denial of services.

Care providers may contact Carelon Medical Benefits Management, Inc. for prior authorization/preservice clinical review/medical necessity reviews of the services listed below through the following options:  Access Carelon Medical Benefits Management’s providerportal.com. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.  Access Carelon Medical Benefits Management via https://Availity.com.  Call Carelon Medical Benefits Management’s Contact Center at 866-714-1107, Monday to Friday, 8 a.m. to 5 p.m.

For benefits to be paid, the member must be eligible on the date of service, and the service must be a covered benefit under the policy. This list is subject to change and is not all-inclusive.

Category description Responsible party Comments Ablative Techniques as a Treatment for Barrett’s
Esophagus Anthem

Admissions: • Elective admissions • Emergency admissions — Anthem must be notified within 48 hours or two business days. • Gastric bypass surgery • Human organ and bone marrow/stem cell transplants • Inpatient hospice • Inpatient rehabilitation admissions • Inpatient skilled nursing facility admission • Obstetrical (OB) related medical stay; excludes childbirth Anthem

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Category description Responsible party Comments Ambulance services: air and Water Anthem

Bariatrics Carelon Medical Benefits Management or Anthem

Base surgical Carelon Medical
Benefits
Management

Behavioral health services — partial hospital program (PHP): • Intensive outpatient programs (IOP) • Intensive in-home services • Transcranial magnetic stimulation (TMS) • Applied behavior analysis (ABA) • Extended day treatment • All facility-based care — inpatient admissions,
residential care Anthem Contact Behavioral Health at 800-934-0331 Biofeedback and neurofeedback Anthem

Blepharoplasty, blepharoptosis repair, and brow lift Anthem

Cardiac electrophysiological studies (EPS) and catheter ablation Anthem

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Category description Responsible party Comments Cardiovascular: • Arterial ultrasound • Cardiac catheterization
• Cardiac devices • Coronary angiography
• Noninvasive diagnostic vascular studies
• Percutaneous coronary intervention (PCI)
Carelon Medical
Benefits
Management

Catheter-based embolization procedures for malignant lesions outside the liver Anthem

Certain outpatient utilization management services Carelon Medical
Benefits
Management

Cochlear implants and auditory brainstem implants Anthem

Cooling devices and combined cooling/heating devices Anthem

Cosmetic and reconstructive procedures of the skin, head, neck, trunk, groin, and extremities Anthem

Cryosurgical, radiofrequency, microwave, or laser ablation to treat solid tumors outside the liver Anthem

Deep brain, cortical, and cerebellar stimulation Anthem

Diaphragmatic/phrenic nerve stimulation and diaphragm pacing systems
Anthem

Durable medical equipment Anthem

Echocardiology: • Stress echocardiography (SE) • Transesophageal echocardiography (TEE) • Resting transthoracic echocardiography (TTE) Carelon Medical
Benefits
Management

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Category description Responsible party Comments Extracorporeal shock wave therapy Anthem

Fertility Carelon Medical
Benefits
Management

Functional electrical stimulation (FES), threshold
electrical stimulation (TES) Anthem

Gastrointestinal endoscopy (EGD) in adults Carelon Medical
Benefits
Management Site of Care for certain surgical services Gene therapy for: beta thalassemia, Duchenne muscular dystrophy, hemophilia, ocular conditions, spinal muscular atrophy, sickle cell disease Anthem

Genetic testing Carelon Medical
Benefits
Management

Home parenteral nutrition Anthem

Hyperbaric oxygen therapy (systemic/topical) Anthem

Hysterectomy Anthem

Implantable peripheral nerve stimulation devices as a treatment for pain Anthem

Infertility treatment Anthem

Intraocular anterior segment aqueous drainage devices (without extraocular reservoir) Anthem

Lab/pathology Anthem

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Category description Responsible party Comments Maternity admissions — vaginal and Cesarean deliveries if more than two days or r days respectively Anthem

Medical diagnostic/treatment services Anthem

Medical oncology drugs Carelon Medical
Benefits
Management

Musculoskeletal: • Joint surgeries/replacements • Pain management injections
• Spinal surgery
Carelon Medical
Benefits
Management

Nuclear cardiology Carelon Medical
Benefits
Management

Oral, pharyngeal, and maxillofacial surgical treatment for obstructive sleep apnea or snoring Anthem

Orthotics and prosthetics Anthem

Out-of-network referrals/services Anthem

Physical therapy, occupational therapy, and speech therapy Carelon Medical
Benefits
Management Includes site-of-care review Private duty nursing in the home setting Anthem

Radiation therapy: • Intensity-modulated radiation therapy (IMRT) • Proton beam • Brachytherapy • Stereotactic radiosurgery (SRS) • Stereotactic body radiotherapy (SBRT)
Carelon Medical
Benefits
Management

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Category description Responsible party Comments Radiology: • Computerized tomography (CT)
• Magnetic resonance angiography (MRA) • Magnetic resonance imaging (MRI) • Myocardial sympathetic innervation imaging with or without SPECT
• Positron emission tomography (PET) Carelon Medical
Benefits
Management

Selected blood, serum, and cellular allergy and toxicity tests Anthem

Selected diagnostic testing Carelon Medical Benefits
Management or
Anthem

Selected surgery, for example: • Breast procedures, including reconstructive surgery,
• implants and other breast procedures • Cranial/facial surgery
• Nasal/sinus surgery • Panniculectomy and abdominoplasty • Partial left ventriculectomy • Penile prosthesis implantation • Scoliosis surgery • Temporomandibular disorders • Treatment of varicose veins (lower extremities) • Uterine fibroid ablation: laparoscopic, percutaneous, or transcervical image-guided techniques Anthem

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Category description Responsible party Comments Site-of-care review for select surgical services Carelon Medical
Benefits
Management

Sleep testing and treatment: • Multiple sleep latency test (MSLT) • Polysomnography, home sleep study, and home portable monitors
Carelon Medical
Benefits
Management

Specialty pharmacy medications CarelonRx, Inc. Requirements can be found at Pharmacy Information Overview Stem cell/bone marrow transplant (with or without myeloablative therapy) and donor leukocyte infusion Anthem Contact the Anthem transplant unit at 888-574-7215 Therapeutic apheresis
Anthem

Transplant services Anthem Contact Anthem Transplant unit at 888-574-7215 Vagus nerve stimulation Anthem

Vascular services Carelon Medical
Benefits
Management

Wearable cardioverter defibrillators Anthem