Imperial County – Community Health Plan of Imperial Valley (CHPIV) Form

Effective: April 1, 2026 Prior Authorization Requirements California Community Health Plan of Imperial Valley (CHPIV) Medi-Cal fee-for-service (FFS) members The following services, procedures and equipment are subject to prior authorization (PA) requirements (unless specified as notification required only), as indicated by “X.” If “X” is not present, PA may not be required or the service, procedure or equipment may not be a covered benefit. PA is guaranteed only as of the time of access to this list. Medical necessity – Medical necessity must exist for any plan benefit to be a covered service whether a PA is required or not. Services that require PA vs. covered services – This PA list contains services that require PA only and is not a list of covered services. The member’s Evidence of Coverage (EOC) provides a complete list of covered services. EOCs are available on the Medi-Cal member page at bit.ly/CHPIV-EOC under Medi-Cal Member Handbooks. Eligibility rules and limitations – Providers are responsible for verifying member eligibility through the Provider Services Center prior to providing care. Even if a service or supply is authorized, eligibility rules and limitations will still apply – all services, procedures, equipment, and outpatient pharmaceuticals are subject to benefit plan coverage limitations. Submit a PA request – • Send the request via fax, phone or online. • The request should be submitted to Health NetHealth Net Community Solutions, Inc. is a subsidiary of Health Net, LLC and Centene Corporation. Health Net is a registered service mark of Health Net, LLC. All other identified trademarks/service marks remain the property of their respective companies. All rights reserved. using the contact information on page 16 unless noted differently in the requirements list. • Attach pertinent medical records, treatment plans, test results, and evidence of conservative treatment to support the medical appropriateness of the request. • For more submission instructions, see Prevent Prior Authorization Delays With These Submission Guidelines. PA timelines – If the request is for … Submit prior authorization request: An elective in patient or outpatient service or procedure. As soon as the need for service is identified. A routine request or procedure. At least 7 calendar or 5 business days (whichever comes first) before a scheduled procedure. An urgent request or procedure. 72 hours before a scheduled procedure. Emergency services do not require prior authorization. PA limitations and exclusions are found on page 13 and sensitive, confidential or other services that do not require prior authorization for Medi-Cal members are provided on pages 14–15. Community Health Plan of Imperial Valley (“CHPIV”) is the Local Health Authority (LHA) in Imperial County, providing services to Medi-Cal enrollees in Imperial County. CHPIV contracts with Health Net Community Solutions, Inc. to arrange healthcare services for CHPIV enrollees. Effective: April 1, 2026, updated May 20, 2026 Page 1 of 16

Community Health Plan of Imperial Valley Medi-Cal INPATIENT SERVICES1
1Procedures performed during acute inpatient hospitalization are included under the inpatient prior authorization (excluding experimental and investigational procedures). Procedures in emergency situations do not require prior authorization. Adult Members Ages 21 and Over Pediatric Members Under Age 21 Skilled nursing facilities All elective admissions X X All elective medical and surgical inpatient hospitalizations Includes, but is not limited to: • Acute care hospital • Acute or sub-acute rehabilitation facility • Musculoskeletal procedures for adult members authorized by Turning Point Healthcare Solutions, LLC X X All emergency hospitalizations within 24 hours of hospital admission • Notification required only • Contact the Hospital Notification Fax Line X X All hospitalizations to a nonparticipating hospital once emergency stabilization is complete X X Long-term care nursing facility admissions Contact the Long-Term Care Intake Line X X OUTPATIENT PROCEDURES, SERVICES OR EQUIPMENT Ablative techniques for treating Barrett’s esophagus, prostate tumors and for treatment of primary and metastatic liver malignancies X X Acupuncture • Contact American Specialty Health Plans, Inc. (ASH Plans) • Authorization not required for initial evaluation X X Balloon angioplasty X X Bariatric surgeries, such as laparoscopic gastric banding X X Behavioral health (outpatient services) • Authorized by the Behavioral Health Team • Includes: − Applied behavioral analysis (ABA) and other forms of behavioral health treatment for autism and pervasive developmental disorders − Out-of-network access − Psychological and neuropsychological testing − Transcranial magnetic stimulation (TMS) • PA not required for in-network psychotherapy and medication management X X Bronchial thermoplasty X X Capsule endoscopy X X Effective: April 1, 2026, updated May 20, 2026 Page 2 of 16

Community Health Plan of Imperial Valley Medi-Cal OUTPATIENT PROCEDURES, SERVICES OR EQUIPMENT, CONTINUED Adult Members Ages 21 and Over Pediatric Members Under Age 21

Effective: April 1, 2026, updated May 20, 2026 Page 3 of 16
Cardiac procedures All cardiac procedures for pediatric members require PA

X For adult members, PA is required for
• Intravascular stent • Percutaneous transluminal coronary angioplasty additional artery branch • Therapeutic vascular embolization • Transluminal angioplasty on an additional unilateral tibial or peroneal artery X

Clinical trials To receive urgent status for routine services requiring authorization related
to a clinical trial, include the Attestation form in your request or indicate “Routine Care Cost Services Associated with the Clinical Trial” X X Cochlear implants X X Community-Based Adult Services (CBAS) • PA is required for greater than 5 visits per week • CBAS services with 1-5 visits per week require notification only • Fax authorization and notifications to: 833-581-5908 X X Custom orthotics

X X Dental anesthesia Intravenous (IV) moderate sedation and deep sedation/general anesthesia X X Developmental screening PA required for ages 6–20 X Diagnostic procedures Authorized by Evolent Specialty Services, Inc. (Evolent) • Advanced imaging: − Computed tomography (CT)/computed tomography angiography (CTA) − Magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA) − Positron emission tomography (PET) scan • Cardiac imaging: − Coronary computed tomography angiography (CCTA) − Myocardial perfusion imaging (MPI) − Multigated acquisition (Muga) scan X X

Community Health Plan of Imperial Valley Medi-Cal OUTPATIENT PROCEDURES, SERVICES OR EQUIPMENT, CONTINUED Adult Members Ages 21 and Over Pediatric Members Under Age 21 Effective: April 1, 2026, updated May 20, 2026 Page 4 of 16
Durable medical equipment (DME) All DME for pediatric members requires PA

X Adult members including, but not limited to: • BiLevel positive airway pressure (BiPAP) • Bone growth stimulator • Continuous glucose monitoring • Custom-made items • Hospital beds and mattresses
• Incontinence supplies beyond 186 units per calendar month or the $165 benefit limitation — whichever is greater • Items with total Medi-Cal purchase price g reater than $1,500
• Oxygen • Power wheelchairs • Scooters • Ventilators

X

Electroencephalogram (EEG)

X X Enteral nutrition products

X X Experimental/investigational services and new technologies Includes, but is not limited to, those listed in the Investigational Procedures List located on the Health Net provider website at provider.healthnet.com > Working with Health Net > Medical Policies > Investigational Procedure List X X Gender reassignment services (Transgender services) X X Genetic testing

X X H. pylori (Helicobacter pylori) antibody testing

X X Hernia repair

X X Hyperbaric oxygen therapy

X X Implantable pain pumps Authorized by TurningPoint Healthcare Solutions, LLC X X Intensive cardiac rehabilitation

X X Joint surgeries Includes ankle, hip, knee, and shoulder • Adult members authorized by TurningPoint Healthcare Solutions, LLC • Pediatric members authorized by Health Net, on behalf of CalViva Health X X Leg stent bridge

X X Lung volume reduction

X X Maze procedures

X X Medications requiring prior authorization Contact the Pharmacy Services X X Neuro and spinal cord stimulators, including procedures • Adult members authorized by TurningPoint Healthcare Solutions, LLC • Pediatric members authorized by Health Net, on behalf of CalViva Health X X Orthognathic procedures (includes TMJ treatment)

X X

Community Health Plan of Imperial Valley Medi-Cal OUTPATIENT PROCEDURES, SERVICES OR EQUIPMENT, CONTINUED Adult Members Ages 21 and Over Pediatric Members Under Age 21 Effective: April 1, 2026, updated May 20, 2026 Page 5 of 16
Out-of-network providers and services • Services rendered by out-of-network providers require PA Excludes emergency services and self-referral services allowed under the Medi-Cal plan for family planning, pregnancy termination, HIV counseling and testing, immunizations at the local health department, and sexually transmitted infections (STIs) X X Outpatient infusion therapy Includes, but is not limited to, blood transfusions and chemotherapy X X Palliative care

X X Private duty nursing services Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services X X Proprietary laboratory analyses Includes the following CPT® codes: 0457U, 0459U, 0462U, 0468U, 0472U, 0577U, 0579U, 0591U, 0596U, 0598U, 0599U, 0641U, 0615U X X Prosthetics

X Quantitative drug screening

X X Radiation therapy All radiation therapy for pediatric members requires PA

X For adult members, limited to: • Intensity modulated radiation therapy (IMRT) • Neutron beam therapy • Proton beam therapy • Stereotactic radiosurgery and stereotactic body radiotherapy (SBRT) X

Reconstructive and cosmetic surgery, services and supplies Surgery, services, and supplies, including, but not limited to: • Bone alteration or reshaping, such as osteoplasty • Breast reduction and augmentation except when following a mastectomy (includes for gynecomastia o r macromastia) • Dermatology, such as chemical exfoliation and electrolysis, dermabrasions and chemical peels, laser treatment or skin injections and implants • Excision, excessive skin and subcutaneous tissue (including lipectomy and panniculectomy) of the abdomen, thighs, hips, legs, buttocks, forearms, arms, hands, submental fat pad, and other areas • Eye or brow procedures, such as blepharoplasty, brow ptosis or canthoplasty • Muscle flap • Nasal surgery, such as rhinoplasty or septoplasty • Otoplasty • Penile implant • Treatment of varicose veins X X Rehabilitation services Physical, occupational and speech therapy require authorization after 12 combined visits. Includes home setting

X Sacroiliac (SI) joint injections

X X

Community Health Plan of Imperial Valley Medi-Cal OUTPATIENT PROCEDURES, SERVICES OR EQUIPMENT, CONTINUED Adult Members Ages 21 and Over Pediatric Members Under Age 21 Effective: April 1, 2026, updated May 20, 2026 Page 6 of 16
Sleep studies Facility based sleep testing X X Spinal surgery (includes, but not limited to, laminotomy, diskectomy, vertebroplasty, nucleoplasty, and X-Stop) • Adult members authorized by TurningPoint Healthcare Solutions, LLC • Pediatric members authorized by Health Net, on behalf of CalViva H ealth X X Surgery (other) All outpatient elective surgery for pediatric members requires PA

X

For adult members: • Bunionectomy • Laparoscopic myomectomy • Laparoscopic retropubic radical prostatectomy • Heel osteotomy • Metatarsal osteotomy • Other • Surgical hammertoe correction • Thyroid surgery • Unlisted laparoscopic procedure involving the abdomen, peritoneum or omentum • Wrist or thumb surgery X

Transplant • Fax request to the Transplant Team • Transplant evaluations and procedures, including, but not limited to, evaluation, transplant consult visits, donor search, and transplant procedure X X Transportation • All non-emergency medical transportation (NEMT) requires a Physician Certification Statement (PCS) − Ground NEMT authorized by the Care Ride Unit (ambulance, ambulatory door- to-door [needs assistance and/or using walker/cane/crutches], gurney/stretcher, wheelchair) − Air transportation (air ambulance), authorized by Health Net, on behalf of CalViva Health • Non-medical transportation (NMT) available upon request by contacting Modivcare (rideshare, passenger car/sedan, taxi, public or private conveyance)

X X Unlisted services and procedures
Services or procedures without a s pecific code
X X Uvulopalatopharyngoplasty (UPPP) and laser- assisted UPPP

X X Ventriculectomy, cardiomyoplasty

X X Vestibuloplasty Surgical procedure X X Wound care Including but not limited to: • Skin substitutes and biologicals • Wound debridement–authorization required after 12 sessions per year

X X

Community Health Plan of Imperial Valley Medi-Cal OUTPATIENT PHARMACEUTICALS (SUBMITTED UNDER MEDICAL BENEFIT) Adult Members Ages 21 and Over Pediatric Members Under Age 21 Medications newly approved by the U.S. Food and Drug Administration (FDA) • Newly approved medications may require PA • Contact Pharmacy Services to confirm if a new medication requires PA X X Self-injectables • Self-injectable medications are the responsibility of the Medi-Cal Rx Program • Refer to the Contract Drug List on the DHCS website for the Medi-Cal Rx list of covered drugs and services. PA may be required; use Cover My Meds to submit a PA request or complete a Prior Authorization Form and fax it to 800-859-4325 • PA required from Pharmacy Services for self-injectable medications administered in a physician’s office X X Testosterone therapy Authorized by Pharmacy Services X X Drug/therapy class • Authorized by the Pharmacy Services • Coram is Health Net’s preferred infusion provider X X Aflibercept agents Examples include: • Ahzantive®, Enzeevu™, Eylea®/Eylea HD, Opuviz™, Pavblu™, Yesafili™ X X Alpha-1 proteinase inhibitors Examples include: • Aralast® NP, Glassia®, Prolastin®-C, Zemaira® X X Bortezomib agents Examples include: • Boruzu™, Velcade® (brand only) X X Corticosteroid ophthalmic injections Examples include: • Dextenza®, Iluvien®, Ozurdex® Retisert®, Xipere®, Yutiq™ X X Denosumab agents Examples include: • Prolia®: Bildyos®, Bosaya®, Conexxence®, Jubbonti®, Ospomyv™, Stoboclo® • Xgeva®: Aukleso™, Bilprevda®, Bomyntra®, Osenvelt®, Wyost®, Xbryk™ X X Eculizumab agents Examples include: • Bkemv™, Epysqli™, Soliris® X X Exon-skipping therapies Examples include: • Amondys-45™, Exondys-51®, Viltepso™, and Vyondys-53® X X Gene therapy, includes CAR-T therapy Examples include: • Abecma®, Adstiladrin®, Aucatzyl®, Beqvez™, Breyanzi®, Carvykti®, Elevidys™, Encelto™, Hemgenix®, Imlygic®, Itvisma®, Kebilidi™, Kymriah™, Lenmeldy™, Luxturna™, Papzimeos™, Roctavian™, Skysona®, Tecartus™, Tecelra®, Yescarta™, Zynteglo®, Zolgensma® • Effective 7/1/2025, gene therapies for sickle cell disease including Casgevy™ and Lyfgenia™ are carved out to Medi-Cal FFS through DHCS *CAR-T therapy X X Effective: April 1, 2026, updated May 20, 2026 Page 7 of 16

Community Health Plan of Imperial Valley Medi-Cal OUTPATIENT PHARMACEUTICALS (SUBMITTED UNDER MEDICAL BENEFIT), CONTINUED Adult Members Ages 21 and Over Pediatric Members Under Age 21 GnRH agonists Examples include: • Camcevi®, Camcevi ETM®, Eligard®, Fensolvi®, Lupron Depot®, Lupron Depot-Ped®, Lutrate® Depot, Supprelin® LA, Triptodur®, Vabrinty™, Zoladez® Camcevi/Camcevi ETM: no PA required for urology/hematology/oncology X X Hereditary angioedema (HAE) agents (See self-injectables) Examples include: • Berinert®, Cinryze®, Dawnzera™, Firazyr®, Haegarda®, Kalbitor®, Ruconest®, Takhzyro® Preferred: Firazyr and Haegarda X X Immune globulin agents Examples include: • Intravenous immunoglobulin (IVIG), Alyglo™, Asceniv®, Bivigam®, Cutaquig®, Cuvitru®, Flebogamma®, GamaSTAN®, Gammagard® Liquid, Gammagard® S/D, Gammaked™, Gammaplex®, Gamunex®-C, Hizentra®, HyQvia®, Octagam®, Panzyga®, Privigen®, Xembify®, Yimmugo® Preferred: Gammagard, Gamunex-C X X Intravenous (IV) iron agents Examples include: • Injectafer®, Monoferric® X X Lysosomal storage disorders Examples include: • Aldurazyme®, Brineura™, Cerezyme®, Elaprase®, Elelyso®, Elfabrio®, Fabrazyme®, Kanuma®, Lamzede®, Lumizyme®, Mepsevii™, Naglazyme®, Nexviazyme®, Pombiliti™, Vimizim®, Vpriv®, Xenpozyme® X X Natalizumab agents Examples include: • Tyruko®, Tysabri® X X Omalizumab agents Examples include: • Omlyclo®, Xolair® X X PD-1/PD-L1 inhibitors Examples include: • Bavencio®, Imfinzi®, Jemperli®, Keytruda®, Keytruda Qlex™, Libtayo®, Loqtorzi™, Opdivo®, Opdivo Qvantig™, Opdualag™, Penpulimab-kcqx, Tecentriq®/Tecentriq Hybreza™, Tevimbra®, Unloxcyt™, Zynyz® X X Pemetrexed agents Examples include: • Alimta®, Axtle™, Pemfexy™, Pemrydi RTU® X X Pulmonary arterial hypertension (PAH) agents Examples include: • PDE-5 inhibitors: Revatio® • Prostacylin analogues/receptor agonist injection: Flolan®, Remodulin®, Veletri® • Prostacylin analogues (PCA) inhalation: Tyvaso®, Ventavis® X X Ranibizumab agents Examples include: • Byooviz™, Cimerli™, Lucentis®, Susvimo™ X X Effective: April 1, 2026, updated May 20, 2026 Page 8 of 16

Community Health Plan of Imperial Valley Medi-Cal OUTPATIENT PHARMACEUTICALS (SUBMITTED UNDER MEDICAL BENEFIT), CONTINUED Adult Members Ages 21 and Over Pediatric Members Under Age 21 Tocilizumab agents Examples include: • Actemra®, Avtozma ®, Tofidence™, Tyenne® X X Ustekinumab agents Examples include: • Imuldosa™, Otulfi®, Selarsdi®, Stelara®, Steqeyma®, Pyzchiva®, Wezlana™, Yesintek™ Preferred: Otulfi, Selarsdi, Steqeyma, Pyzchiva,Yesintek X X Viscosupplementation agents Examples include: • Durolane®, Euflexxa®, Gelsyn-3™, Gel-One®, GenVisc® 850, Hyalgan®, Hymovis®, Monovisc®, Orthovisc®, Supartz FX™, Synojoynt™, Synvisc®, Synvisc One®, Triluron™, TriVisc™, VISCO-3 TM Preferred: Euflexxa, Monovisc, Orthovisc, Synvisc and Synvisc One X X Effective: April 1, 2026, updated May 20, 2026 Page 9 of 16

Community Health Plan of Imperial Valley Medi-Cal Outpatient Pharmaceuticals (submitted under medical benefit)

• Abrilada™
• Adakveo®
• Adcetris®
• Adzynma™
• Akynzeo®
• Aliqopa™
• Amtagvi™
• Amvuttra®
• Anktiva®
• Aphexda
• Aristada®
• Arzerra®
• Asparlas™
• Azedra®
• Bizengri®
• Beleodaq®
• Benlysta®
• Beovu®
• Besponsa®
• Blincyto®
• Botox®
• Briumvi®
• Cablivi®
• Ceprotin®
  (ages 0–20 only)
• Cimzia®
• Cinqair®
• Columvi™
• Cortrophin®
• Cosela™
• Cosentyx®
• Crysvita®
• Cyramza®
• Danyelza®
• Darzalex®/Darzalex Faspro
• Datroway®
• Daxxify®
• DDAVP® injectable
  (ages 0–20 only)
• Dupixent®
• Durysta™
• Dysport®
• Elahere™
• Elrexfio™
• Elzonris®
• Empaveli™
• Empliciti®
• Emrelis™
• Enjaymo™
• Entyvio™
• Epkinly™
• Erbitux®
• Erwinaze®
  (ages 0–20 only)
• Evenity®
• Evkeeza™
• Fasenra™
• Faslodex®
• Folotyn®
• Furoscix®
• Fyarro™
• Gamifant®
• Gazyva®
• Givlaari®
• Grafapex™
• H.P. Acthar® Gel
• Halaven®
• Hepzato®
• iDose® TR (implant)
• Ilaris®
• Ilumya®
• Imaavy™
• Imdelltra™
• Imjudo®
• Inlexzo™
• Izervay™
• Jelmyto™
• Jesduvroq™
• Jevtana®
• Jobevne™
• Ketalar®
• Kimmtrak®
• Kisunla®
• Krystexxa®
• Kyprolis®
• Lantidra™
• Lemtrada®
• Leqembi™
• Leqvio®
• Leukine®
• Levoleucovorin
• (Khapzory™)
• Lumoxiti®
• Lunsumio™
• Lutathera®
• Lymphir™
• Lynozyfic™
• Macugen®
• Margenza™
• Marquibo®
• Monjuvi®
• Mozobil®
• Mylotarg™
• Myobloc®
• Myozyme®
• Niktimvo™
• Novantrone®
• Nplate®
• Nucala
• Nulibry™
• Nulojix®
• Ocrevus™
• Ocrevus Zunovo®
• Ohtuvayre™
• Omisirge®
• Omvoh™
• Oncaspar®
• Onpattro™
• Orencia®
• Oxlumo™
• Padcev®
• Palperidone palmitate
• Panhematin®
• Parsabiv®
• Perjeta®
• Phesgo®
• PiaSky®
• Pluvicto®
• Polivy™
• Poteligeo®
• Prevymis™
• Provenge®
• Qalsody™
• Radicava™
• Radiesse®
• Reblozyl®
• Rebyota™
• Rethymic® (implant)
• Revcovi™
• Rybrevant™
• Rylaze™
• Ryoncil®
• Ryplazim®
• Rystiggo®
• Rytelo®
• Sandostatin® LAR kit
• Saphnelo™
• Sarclisa®
• Scenesse®
• Sculptra®
• Signifor® LAR
• Simponi Aria®
• Sinuva®
• Skyrizi®
• Somatuline® Depot
• Sotradecol®
• Spevigo®
• Spinraza™
• Spravato®
• Sustol®
• Syfovre™
• Synagis®
• Synribo®
• Talvey™
• Tecvayli™
• Tepezza®
• Testopel®
• Tezspir®
• Thyrogen®
• Tivdak™
• Tremfya®
• Trodelvy®
• Tzield™
• Ultomiris™
• Unituxin®
• Uplizna®
• Vabysmo®
• Valstar®
• Vectibix®
• Veopoz™
• Vidaza®
• Visudyne®
• Vyalev™
• Vyepti™
• Vyjuvek®
• Vyloy®
• Vyvgart®
• Vyvgart® Hytrulo
• Vyxeos®
  (ages 0-20 only)
• Xeomin®
• Xiaflex®
• Yervoy®
• Zaltrap®
• Zemdri™
• Zepzelca™
• Zevaskyn™
• Ziihera®
• Zilretta™
• Zinplava™
• Zulresso™
• Zusduri™
• Zynlonta® For the reference product, all generics or biosimilar drugs will require a prior authorization. Effective: April 1, 2026, updated May 20, 2026 Page 10 of 16

Community Health Plan of Imperial Valley Medi-Cal Outpatient Pharmaceuticals (submitted under medical benefit)
Biosimilars are required in lieu of branded drugs • Biosimilars require prior authorization • Preferred biosimilars are required in lieu of branded drugs • Authorized by the Pharmacy Department • Must try preferred products prior to non-preferred approval. Please refer to the drug specific policy for complete list of preferred products. Non-Preferred Preferred Bevacizumab agents – no PA required for ophthalmologists Alymsys®, Avastin®, Avzivi®, Vegzelma®
Mvasi®, Zirabev™ – no PA required for ophthalmologists Erythropoiesis-stimulating agents (ESA) – Aranesp®, Epogen®, Mircera®, Procrit® Retacrit™ (PA not required for Retacrit when administered/provided under the medical benefit) Filgrastim agents – Granix®, Neupogen®, Nypozi™, Releuko® Nivestym®, Zarxio® (PA not required for Zarxio when administered/provided under the medical benefit) Infliximab agents – Remicade® Avsola®, Inflectra®, Renflexis® Pegfilgrastim agents – Fulphila®, Fylnetra®, Neulasta®, Neulasta OnPro®, Rolvedon™, Ryzneuta™, Stimufend®, Ziextenzo® Nyvepria®, Udenyca®, Udenyca Onbody Rituximab agents – Riabni®, Rituxan®, Rituxan Hycela® Ruxience®, Truxima® (no PA required for hematology/oncology indications) Trastuzumab agents – Enhertu®, Herceptin®, Herceptin Hylecta™, Hercessi™, Herzuma®, Kadcyla®, Ontruzant® Kanjinti®, Ogivri®, Trazimera™ Effective: April 1, 2026, updated May 20, 2026 Page 11 of 16

Community Health Plan of Imperial Valley Medi-Cal CALAIM BENEFITS AND SERVICES REQUIRING PRIOR AUTHORIZATION Community Supports non-benefit services • Assisted Living Facility Transitions • Asthma Remediation • Day Habilitation • Environmental accessibility adaptations (home modifications) • Housing Deposits • Housing Tenancy and Sustaining Services • Housing Transition Navigation Services • Meals: Medically Tailored Meals/Medically Supportive Food • Personal Care and Homemaker Services • Recuperative Care (medical respite) • Respite Services • Short-term Post-hospitalization Housing CalAIM benefits • Asthma Preventive Services (greater than 2x per year) • Transitional Rent Refer to the CalAIM Resources for Providers page at https://bit.ly/CalAIM-resources Effective: April 1, 2026, updated May 20, 2026 Page 12 of 16

Community Health Plan of Imperial Valley Medi-Cal Limitations and Exclusions, and Prior Authorization Exceptions Listed below are prior authorization limitations and exclusions, in addition to sensitive, confidential and other services that do not require prior authorization for adult or pediatric Medi-Cal members. LIMITATIONS AND EXCLUSIONS Adult Members Ages 21 and Over Pediatric Members Under Age 21 Authorization for carve-out services not covered by Health Net, such as CCS-eligible conditions, requires prior authorization from the local CCS office. X CCS services must be provided by CCS-paneled providers and at CCS-approved facilities. X Any services related to CCS-eligible medical conditions must be approved by the CCS program. Refer to the California Code of Regulations, Title 22, Division 2, Part 2, Subdivision 7, CCS, Chapter 4, Medical Eligibility, Article 4, available online at www.calregs.com. X Routine laboratory and radiology services must be performed at a Health Net participating facility. X X Specialty mental health services and select substance use disorder services are covered by the county mental health program. If coordination assistance with the county mental health program is needed, contact Medi-Cal Member Services. X X Emergency room (ER) services after stabilization of an emergency medical condition or when the medical screening exam (MSE) does not demonstrate an emergency medical condition are subject to review by Health Net and may not be paid. X X Cosmetic surgery is not a benefit of the Medi-Cal program. Cosmetic surgery requests are reviewed for possible reconstructive benefits, as well as medical necessity, using the Department of Health Care Services (DHCS) definition of cosmetic surgery. X X Authorizations for services commonly included in the local educational agency (LEA) carve-out are referred to the local school district. These include speech therapy, occupational therapy and audiology services for children ages three and over, and psychological testing for attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD). X A member or provider is not required to obtain prior authorization for NEMT services if the member is being transferred from an emergency room to an inpatient setting, or from an acute care hospital, immediately following an inpatient stay at the acute level of care, to a skilled nursing facility, an intermediate care facility or imbedded psychiatric units, free standing psychiatric inpatient hospitals, psychiatric health facilities, or any other appropriate inpatient acute psychiatric facilities. X X Effective: April 1, 2026, updated May 20, 2026 Page 13 of 16

Community Health Plan of Imperial Valley Medi-Cal SENSITIVE, CONFIDENTIAL OR OTHER SERVICES THAT DO NOT REQUIRE PRIOR AUTHORIZATION Adult Members Ages 21 and Over Pediatric Members Under Age 21 Referral or prior authorization is not required for the following sensitive services, and the services may be obtained from any qualified in-network or out-of-network provider: • Minor consent services which include treatment for the following: 1) Under age 12 a) Pregnancy and pregnancy related services b) Family planning services c) Sexual assault services 2) Age 12 and older - under 21 a) Pregnancy and pregnancy related services b) Family planning services c) Sexual assault services d) Infectious, contagious, or communicable disease diagnosis and treatment e) Sexually transmitted diseases prevention (or infections), diagnosis, and treatment f) Drug and alcohol abuse treatment and counseling g) Outpatient mental health treatment and counseling. Minors may obtain outpatient mental health services, if in the opinion of the attending professional person determines that the minor is mature enough to participate intelligently in their health care pursuant to Family Code section 6924. h) Intimate partner violence • Adult sensitive care services: − Family planning and birth control including sterilization for adults 21 and older − Pregnancy testing and counseling and other pregnancy related services − HIV/AIDS prevention and testing − Sexually transmitted infections prevention testing and treatment − Sexual assault care − Outpatient abortion services X X Referral or prior authorization is not required for Comprehensive Perinatal Services Program (CPSP) services. Services may be obtained from any participating CPSP providers. Refer to the CPSP website at www.cdph.ca.gov/healthinfo/healthyliving/childfamily/Pages/CPSP.aspx for more information about locating a CPSP provider. X X Effective: April 1, 2026, updated May 20, 2026 Page 14 of 16

Community Health Plan of Imperial Valley Medi-Cal SENSITIVE, CONFIDENTIAL OR OTHER SERVICES THAT DO NOT REQUIRE PRIOR AUTHORIZATION Adult Members Ages 21 and Over Pediatric Members Under Age 21 Hospice services • Inpatient hospice care: Prior authorization is required, subject to Health Net’s standard prior authorization processes. Attach the required documentation (see below) and submit to Health Net - Prior Authorization. • Outpatient hospice services: Prior Authorization is not required for routine home care, continuous home care and respite care, or hospice physician services. Submit all required documentation (see below) via encrypted email to HospiceCTIforms@centene.com. Required documentation: • Certification of the patient’s terminal illness; • Medi-Cal Hospice Program Election form, available online at https://bit.ly/DHCS-MCL-Hospice-Election; • Revocation of hospice election, documenting the patient’s decision to discontinue hospice care; • Copy of the written initial plan of care; • Written prescription signed by the patient’s attending physician, which includes justification for general inpatient level of care; • Face-to-face encounter document that verifies clinical evaluation for continued eligibility; and • Transfer summary when the patient changes health plan carriers Refer to APL 25-008 for additional information X X Other services not requiring prior authorization: • Basic prenatal, maternal and preventive services and care as defined by the most current clinical standards or guidelines of American College of Obstetricians and Gynecologists (ACOG) and Comprehensive Perinatal Services Program (CPSP) • California Prenatal Screening (PNS) Program • Services for emergency medical conditions • Specialist referral (initial referral to participating specialist) • Urgently needed services when the member is outside their county • Certified nurse midwife and obstetrical/gynecological (OB/GYN) services from a participating provider • MOA 638 Indian Health Service facilities • Biomarker testing for an insured with advanced or metastatic stage 3 or 4 cancer (FDA approved) • COVID-19 diagnostic and screening testing • Services that are rendered under the Children and Youth Behavioral Health Initiative fee schedule • Initial mental health and substance use disorder assessments • Adult preventive immunizations from a participating physician or other provider • Second opinion from a participating physician or other provider • Lactation consultation services for pregnant and postpartum Members • Non-hospital-grade (manual and electric) breast pumps X X Effective: April 1, 2026, updated May 20, 2026 Page 15 of 16

Community Health Plan of Imperial Valley Medi-Cal Prior Authorization Contacts Listed below are contact numbers for requesting prior authorization via telephone and fax. Also included is contact information for commonly requested departments and external organizations. If members have questions regarding the prior authorization list or requirements, refer to the member services number listed on their identification card. CONTACT INFORMATION MEMBERS Ages 21 and Over Under Age 21 Prior authorization request 833-236-4141; fax: 800-743-1655; provider.healthnetcalifornia.com X X Hospital Notification Unit fax: 800-676-7969 X X Hospital Notification Unit/Post-stabilization Notification 800-995-7890 X X Long-term Care Intake Line 800-453-3033; fax: 855-851-4563 X X American Specialty Health Plans, Inc. (ASH Plans) 800-972-4226; www.ashlink.com X X Behavioral Health Team 844-966-0298 X X California Children’s Services (CCS) www.dhcs.ca.gov/services/ccs/pages/default.aspx (includes CCS contact information by county) X Care Ride Unit (NEMT prior authorization) Fax: 833-701-0051 X X CCS paneling inquiries www.dhcs.ca.gov/services/ccs/Pages/ProviderEnroll.aspx (916) 552-9105 – select option 5, then option 2 X Coram Specialty Infusion Services (preferred home infusion provider) 866-899-1661; fax: 866-843-3221 X X County Mental Health for substance abuse services www.dhcs.ca.gov/services/Pages/MentalHealthPrograms-Svcs.aspx (includes contact list by county) X X Dental (Denti-Cal) 800-322-6384 X X Eligibility and benefits 833-236-4141 X X Evolent Specialty Services, Inc. (Evolent) (for advanced and cardiac imaging requests) 855-510-3720 Online submission: www.radmd.com/ X X Medi-Cal general information www.medi-cal.ca.gov X X Medi-Cal Member Services Department 888-893-1569 X X Modivcare non-emergency and non-medical ground transportation services (NEMT/NMT) scheduling 855-251-7097 fax: 877-457-3352 X X Nurse Advice Line 833-236-4141 (TTY: 711), 24 hours, seven days a week X X Pharmacy Services 800-867-6564, option 2; fax: 833-953-3436 X X Provider Services Center 833-236-4141 X X Public Programs (for CBAS) Face-to-face, authorization and notification request: fax: 833-581-5908 X X Transplant Team fax: 833-769-1141 X X TurningPoint Healthcare Solutions, LLC (for musculoskeletal requests) 855-332-5898; fax: 949-774-2254 www.myturningpoint-healthcare.com email: centenecaum@turningpoint-healthcare.com X Effective: April 1, 2026, updated May 20, 2026 Page 16 of 16