PROVIDER

ALERT

*CORRECTED* Prior Authorization List Updates

Effective 07/01/2021

April 30th, 2021

The Northwest Physicians Network (NPN)/OptumCare Network (OCN) will require prior authorization and medical necessity review for the following codes in addition to the codes previously on the Prior Authorization List (PAL). This will be effective July 1st, 2021.

HCPCS Code HCPCS Description C9399 Unclassified biologics, chemotherapy, or other drugs J0178 Eylea, aflibercept J0179 Beovu, brolucizumab-dbll J0567 Brineura, cerliponase alfa J1096 Dextenza, dexamethasone (lacrimal) J1428 Exondys 51, eteplisren J1429 Vyondys 53, golodirsen J1446 Granix, Tbo-filgrastim J2503 Macugen, pegaptanib sodium J2778 Lucentis, ranibizumab J3490 Unclassified biologics, chemotherapy, or other drugs J3590 Unclassified biologics, chemotherapy, or other drugs J3999 Unclassified biologics, chemotherapy, or other drugs J7311 Retisert, fluocinolone acetonide J7312 Ozurdex, dexamethasone J7313 Iluvien, fluocinolone acetonide J7314 Yutiq, fluocinolone acetonide J7318 Durolane, hyaluronic acid J7325 Synvisc, hyaluronic acid J7328 Gelsyn-3, hyaluronic acid J9310 Rituxan, rituximab J9999 Unclassified biologics, chemotherapy, or other drugs Q5104 Renflexis, infliximab-abda Q5122 Nyvepria, pegfilgrastim-apgf C9449 Blincyto, blinatumomab Q5103 Inflectra, infliximab-dyyb Prior Authorization Request Form *YOU MUST SUBMIT CLINICAL DOCUMENTATION TO SUPPORT YOUR REQUEST

PLEASE NOTE – AUTHORIZATIONS MAY BE REQUESTED ONLINE VIA ONEHEALTHPORT

DATE: ______ Humana HMO Medicare Advantage  Premera HMO Medicare Advantage Phone: 1-877-836-6806  UnitedHealthcare AARP West Medicare Advantage Fax: 1-855-402-1684  UnitedHealthcare Community & State (Apple Health)

Routine Urgent

Urgent is defined as a medical or behavioral health condition manifesting itself by acute symptoms of sufficient severity such that if services are not received within 24 hours of the request the person’s situation is likely to deteriorate to the point that emergent services are necessary. *INPATIENT NOTIFICATIONS/SNF ADMISSIONS – FAX TO 253-627-4708* Patient Name: Member ID:

DOB: Phone Number:

Requesting Provider: Servicing Provider:

NPI: TIN: NPI: TIN:

Address: Address:

Phone: Phone:

Fax: Fax:

Inpatient Outpatient

Diagnosis and ICD-10 code(s): Date of Service:

CPT Code(s): Quantity: Facility Information: NPI: TIN:

Comments:

PLEASE NOTE: This Authorization does not ensure payment of services. All claims are subject to normal policy limitations, current eligibility, and plan requirements. AUTHORIZATION LETTERS WILL BE FAXED TO PCP & SERVICING PROVIDER UPON PROCESSING.

Submit Claims to: Optum Care Network Electronic ID: Life1 Clearinghouse: Optum 360 Effective 2/17/2021 PAYMENT SUBJECT TO CURRENT ELIGIBILITY AT THE TIME OF SERVICE