Revised Prior Authorization Requirements

For Health Net Health Plan of Oregon, Inc. Commercial Members

At Health Net Health Plan of Oregon, Inc. (Health Net), we regularly review the Prior Authorization List (PAL) to ensure our members receive safe and appropriate medical care. As a valued employer group with Health Net, we want you to be aware of PAL changes that may affect your client’s health care coverage.

Effective January 1, 2015, we have revised our commercial [EPO, Point of Service (POS), CommunityCare, and PPO] PAL requirements. Significant changes to the list are indicated below. For a complete copy of the PAL requirements, please log in to our website at www.healthnet.com, click on Preauthorizations under My Coverage > Prior Authorization List, or call
1-888-802-7001.


Changes to Commercial Prior Authorization Requirements for Health Net Health Plan of Oregon, Inc. commercial EPO, Point of Service (POS), CommunityCare, and PPO
Prior authorization no longer required:

  • Home Health services
  • Home Hospice services
  • Select outpatient pharmaceuticals including: Boniva®, Flolan®, Novantrone®, Omontys®, Prolia®, Reclast®, Xgeva®

 

Changes made to existing authorization requirements:

  • Behavioral health: “Includes neuropsych testing ordered by a psychiatrist” added in comments.
  • Blepharoplasty: Changed to Blepharoplasty (includes brow ptosis).
  • Occupational and speech and physical therapy: “Includes home setting” added in comments.
  • Radiation therapy prior authorization requirement no longer limited to intensity modulated radiation therapy (IMRT), proton beam therapy and stereotactic radiosurgery and stereotactic body radiotherapy (SBRT).
  • Rituxan® (rheumatoid arthritis only) changed to Rituxan (non-oncology only).

 

New outpatient procedures, services or equipment requiring prior authorization:

  • Cardiac catheterization,
  • Echocardiography,
  • Enhanced external counterpulsation,
  • Outpatient pharmaceutical: Entyvio™,
  • Potentially cosmetic or reconstructive services including:
    • Dermatology (in-office procedures), including:
      » chemical exfoliation, electrolysis (17360–17380);
      » dermabrasion/chemical peel (15780–15793);
      » laser treatment (17106–17108, 17250);
      » skin injections and implants (11900–11980).
    • Excision, excessive skin and subcutaneous tissue (including lipectomy) of the abdomen, thighs, hips, legs, buttocks, forearms, arms, hands, submental fat pad, and other areas;
      • Liposuction;
      • Otoplasty;
      • Panniculectomy;
      • Transgender services;
      • Vermilionectomy;
      • Vestibuloplasty.
    • Total joint replacements.

 

ADDITIONAL INFORMATION
Oregon EPO, POS, CommunityCare, and PPO subscribers will be sent this information by October 31, 2014. If they have questions regarding the information, they should contact the Health Net Customer Contact Center either online at www.healthnet.com, or by telephone at 1-888-802-7001. Customer Contact Center hours are Monday through Friday, 7:30 a.m. to 5:00 p.m., except holidays.
LTR000766EW00_EMP (10/14) Health Net Health Plan of Oregon, Inc. is a subsidiary of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. All other identified trademarks/service marks remain the property of their respective companies. All rights reserved.

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