CHAPTER 5: ANCILLARY SERVICESCHAPTER 5: ANCILLARY SERVICESCHAPTER 5: ANCILLARY SERVICESCHAPTER 5: ANCILLARY SERVICES A. LABORATORY.................................................................................................................. 52

LABORATORY POLICIES AND PROCEDURES .......................................................................................... 52

COMMERCIAL LABORATORIES......................................................................................................................

HOSPITAL LABORATORIES ............................................................................................................................

LABORATORY EXCEPTION LIST ............................................................................................................... 54

B. RADIOLOGY..................................................................................................................... 57 PRIVILEGING BY SPECIALTY..................................................................................................................... 57

IMAGING REQUIRING PRECERTIFICATION............................................................................................ 59

C. PHYSICAL AND OCCUPATIONAL THERAPY............................................................ 69 CPT CODES REQUIRING ORTHONET AUTHORIZATION ................................................................... 69

D. PHARMACY...................................................................................................................... 70 PHARMACY BENEFITS MANAGER ............................................................................................................ 70

THREE-TIER PRESCRIPTION DRUG BENEFIT........................................................................................ 70

PHARMACY MANAGEMENT PROGRAMS ................................................................................................. 71

CAREMARK .......................................................................................................................................................

THE FORMULARY ........................................................................................................................................ 73

A. LABORATORY A. LABORATORY A. LABORATORY A. LABORATORY Quest Diagnostics manages Oxford�s laboratory network. The network is composed of:

• Full-service labs, including Quest labs and subcontracted labs participating with Quest Network Laboratory

• Niche labs (e.g., esoteric/specialty labs) • Hospital labs (note that a participating hospital may not be a participating laboratory)

Laboratory Policies and ProceduresLaboratory Policies and ProceduresLaboratory Policies and ProceduresLaboratory Policies and Procedures

• As an Oxford participating provider, your contract requires you to refer Members to other participating providers for covered services, except when a referral to a participating provider would not be medically appropriate for the Member's care. For outpatient laboratory procedures, this means that, for Members, you must send specimens only to laboratories in the Quest Network of laboratories (see list below) except when it would be medically inappropriate to use a Quest laboratory.

• If you are not abiding by this policy, and sending outpatient laboratory work for Members to laboratories that are not in the Quest Network, Oxford may withhold or reduce your compensation. You will be notified via a letter of your usage patterns, and be given an opportunity to conform your referrals to Oxford's policies, prior to the imposition of the withhold or reduction.

• A referral is not required for lab specimens sent to participating laboratories in Oxford�s network. (Only a physician�s script or lab order form is required).

• Outpatient ambulatory surgery, emergency room services and inpatient hospitalization include laboratory services performed on the dates of service of the claim as part of the per diem and case rates, unless otherwise specified by the hospital contract.

CommercialCommercialCommercialCommercial LaboratorLaboratorLaboratorLaboratoriesiesiesies

Quest Diagnostics, Incorporated

Client services, home blood draws, STAT testing services: • Northern and Central New Jersey: 800-631-1390 • Southern New Jersey: 800-825-7320 • Long Island, New York: 800-877-7525 • All Other New York: 800-631-1390 • Connecticut: 800-403-8777 • Patient service center locator number for Members: 800-225-SITE

BioReference Laboratories Inc

Client services: 800-229-5227

Clinical Diagnostic Services

Client services: • New Jersey, Manhattan, Brooklyn, Westchester, and Rockland Counties • Queens, Suffolk and Nassau Counties

800-522-4566 800-624-5227

Clinical Lab Partners

Client services: 860-696-8020

Dianon Systems, Inc.

Client services: 800-328-2666 Enzo Clinical LabsClient services: 800-522-5052

GJL Medical LabsClient services: 800-924-1650

Kyto Meridien Diagnostics, LLC

Client services: 800-999-5986

Laboratory Corporation of America Holdings

Client services, home blood draws, STAT testing services: • New Jersey: 800-223-0631 • New York: 800-745-0233 • Connecticut: 800-342-2475 • Patient service center locator number for Members: 888-LabCorp

PATHOLOGY ASSOCIATES, P.C. Client services: 800-388-3995 Quentin Medical Laboratory, Inc.Client services: 718-492-2600

Shiel Medical Laboratory, Inc.Client services: 800-553-0873

Hospital LaboratoriesHospital LaboratoriesHospital LaboratoriesHospital Laboratories

Continuum Health Partners, Inc.

Beth Israel Medical Center Pathology and Laboratory Medicine 212-420-2126 Long Island Medical College Pathology and Laboratory Medicine 212-420-2126 St. Luke�s�Roosevelt Hospital Pathology and Laboratory Medicine 212-523-8557

Greenwich Hospital LaboratoryClient services: 203-863-3000

Griffin HospitalClient services: 203-732-7280 Hackensack University Medical Center Totalab

Client services: Milford Hospital Laboratory

877-868-2522 or 201-996-4881

Client Services: 203-876-4256

North Shore University Hospital–Long Island Jewish Medical Health System

Client Services: • Nassau and Suffolk counties • Brooklyn and Richmond counties

Only the following hospitals in the North Shore system are participating: North Shore University Hospital Manhasset North Shore Hospital System Central Laboratories Long Island Jewish Medical Center Long Island Jewish Medical Center�Schneider Children�s Hospital Lab Staten Island University Hospital

516-719-1000 718-226-5227

New York Presbyterian Healthcare System

New York Presbyterian Hospital:

• New York Weill Center/New York Hospital Laboratories 212-746-0670

• Columbia Presbyterian Center/ Clinical Lab Services 212-305-8600

The Brooklyn Hospital Center, Department of Pathology 718-250-8027

Laboratory of Dermatopathology, Department of Dermatopathology College of Physicians & Surgeons of Columbia University

212-305-2155

New York Community Hospital of Brooklyn, Department of Pathology & Lab Medicine

718-692-5372

New York Methodist Hospital - Outpatient Laboratory 718-780-3645

New York United Hospital Medical Center Lab 914-934-3083

NYHQ/Charter Diagnostics Laboratory 718-670-2579

Palisades Medical Hospital/Clinical Laboratory 201-854-5054

Wyckoff Heights Medical Center Laboratories 718-963-7519

Laboratory Exception List Laboratory Exception List Laboratory Exception List Laboratory Exception List The laboratory exception list is a list of laboratory procedural codes that Oxford allows its physicians to perform in their offices that will be reimbursed by Oxford. All other lab tests must be performed by one of the participating laboratories in Oxford�s network. Primary Care Physicians and Specialists

*81000 Urinalysis, with microscopy *81002 Urinalysis, non-automated, without microscopy *81003 Urinalysis, automated, without microscopy

81025 Urine pregnancy test, by visual color comparison methods 82270 Blood, occult; feces screening, 1-3 simultaneous determinations 82273 Blood, occult; other sources, qualitative 82962 Glucose, blood sugar by glucometer

83014 Helicobacter Pylori, breath test analysis; drug administration and sample collection (Note: Dianon is providing test kit free of charge � call 800-328-2666)

83026 Hemoglobin; by copper sulfate method, non-automated 85013 Spun microhematocrit 85018 Blood count, hemoglobin 85651 Sedimentation rate, erythrocyte; non-automated

****86403 Particle agglutination, screen, each antibody 86485-86586

Skin tests; various

**87070 Culture, bacterial; any other source but urine, blood or stool, with isolation and presumptive identification of isolates.

**87081 Culture, bacterial, screening only, for single organisms 87177 Ova and parasites, direct smears, concentration and identification 87210 Smear, wet mount with simple stain, for bacteria, fungi, ova, and/or parasites 87220 Tissue examination for fungi (e.g., KOH slide)

****87880 Infectious agent detection by immunoassay � streptococcus group A 88170 Fine needle aspiration, with or without preparation of smears; superficial tissue

88171 Fine needle aspiration, with or without preparation of smears; deep tissue under radiologic guidance

89100 Duodenal intubation and aspiration single specimen plus appropriate test

89105 Duodenal intubation and aspiration; collection of multiple fractional specimens with pancreatic or gallbladder stimulation, single or double lumen tube

89130- 89141

Gastric intubation and aspiration; various

89350 Sputum, obtaining specimen, aerosol-induced technique 99195 Phlebotomy, therapeutic (separate procedure)

***85022 ***85023 ***85024 ***85025

For Stat Purposes Only, claim must be marked STAT. Hemogram, automated and manual differential WBC count (CBC) Hemogram & platelet count, automated and manual differential WBC count (CBC) Hemogram & platelet count, automated and partial differential WBC count (CBC) Hemogram & platelet count, automated and automated complete differential WBC count (CBC)

*, **, ***, ****Reimbursement is limited to one procedure (within the related family of codes) per visit. Pediatricians Only

82247 Bilirubin, Total Obstetricians, Gynecologists, Reproductive Endocrinologists, Infertility Specialists Only

82670 Estradiol 83001 Gonadotropin; follicle stimulating hormone (FSH)

83002 Gonadotropin; luteinizing hormone (LH) 84144 Progesterone 84702 Gonadotropin, chorionic (hCG); quantitative

89250 Culture and fertilization of oocyte(s) 89251 Culture and fertilization of oocyte(s) with co-culture of embryos 89252 Assisted oocyte fertilization, microtechnique (any method)89253 Assisted embryo hatching, microtechniques (any method)89254 Oocyte identification from follicular fluid89255 Preparation of embryo for transfer (any method)89257 Sperm identification from aspiration (other than seminal fluid)

89260Sperm isolation; simple prep (e.g., sperm wash, swim-up) for insemination ordiagnosis w/semen analysis

89261Sperm isolation; complex prep (e.g., Percoll gradient, albumin gradient) forinsemination or diagnosis with semen analysis

89300 Semen analysis; presence and/or motility of sperm including Huhner test (post coital)89310 Semen analysis; motility and count89320 Semen analysis; complete (volume, count, motility and differential)89321 Semen analysis; presence and/or motility of sperm89325 Sperm antibodies 89329 Sperm evaluation; hamster penetration test 89330 Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test

Rheumatologists Only

89060 Crystal identification by light microscopy with or without polarizing lens analysis, and body fluid (except urine)

Hematologists and Oncologists Only

***85022 Hemogram, automated and manual differential WBC count (CBC)

***85023 Hemogram & platelet count, automated and manual differential WBC count (CBC)

***85024 Hemogram & platelet count, automated and partial differential WBC count (CBC)

***85025 Hemogram & platelet count, automated and automated complete differential WBC count (CBC)

85095 Bone marrow; aspiration only 85097 Bone marrow; smear interpretation only, with or without differential cell count 85102 Bone marrow biopsy, needle or trocar

86077 Blood bank physician services; difficult cross-match and/or evaluation of irregular antibody(s), interpretation and written report

86078 Blood bank physician services; investigation of transfusion reaction, including suspicion of transmissible disease, interpretation and written report

86079 Blood bank physician services; authorization for deviation from standard blood-banking procedures, with written report

86915 Bone marrow, modification or treatment to eliminate cell 86927-86999 Transfusion medicine

*** Reimbursement is limited to one procedure per visit. Urologists Only

89300 Semen analysis; presence and/or motility of sperm including Huhner test (post coital)

89310 Semen analysis; motility and count 89320 Semen analysis; complete (volume, count, motility and differential) 89321 Semen analysis; presence and/or motility of sperm

Specimen Handling and Venipuncture

• If specimen handling and venipuncture codes are billed in conjunction with a lab code, only the lab and venipuncture codes will be reimbursed (the lab code must be on the above Laboratory Exception List) Venipuncture is not payable to a laboratory.

• If specimen handling and venipuncture codes are billed without a lab code, the specimen handling and venipuncture codes will be reimbursed per the Oxford fee schedule.

B. RADIOLOGYB. RADIOLOGYB. RADIOLOGYB. RADIOLOGY New York Medical Imaging P.L.L.C. (NYMI), a physician-owned radiology network comprised of leading board-certified radiologists, is Oxford�s network manager for all outpatient commercial and Medicare imaging services. Please note that inpatient, ambulatory surgery, ER radiology services, radiation therapy, radionuclide therapy, ophthalmic ultrasound, and any delegated physician arrangement are not included in this arrangement. Oxford has suspended the requirements to submit referrals for outpatient radiology procedures performed by participating radiologists. Privileging By Specialty The privileging program is designed to improve quality by limiting coverage of imaging services to those provided in the most appropriate setting. Below is a list of imaging CPT codes physicians other than radiologists can perform in their office. Note: The privileging program applies to all settings, including inpatient. *These procedures require pre-certification; call 1-877-PRE-AUTH *** Any studies beyond 3 require pre-certification; call 1-877-PRE-AUTH

OXFORD HEALTH PLANS PRIVILEGING BY SPECIALTY: JANUARY 2002 PHYSICIAN TYPE CPT CODES Description Primary Care Physicians: Internal Med., Fam. Practice

71010-71030 76075,76076

Chest imaging DEXA studies, bone densitometry

Breast Surgeons: AIUM-accredited

76942

Ultrasonic guidance for needle biopsy

Cardiologists Cardiologists � Pediatric only

71010-71030 78464*, 78465*, 78469* 78472*, 78473* 78478* 76825,76826, 76827, 76828

Chest imaging Tomographic SPECT studies Cardiac blood pool imaging Wall motion study Echocardiography, fetal

Chiropractors 72010, 72040, 72069, 72070, 72080, 72100

Spine imaging

Endocrinologists

76075, 76076

76942 76536 (AACE Accredited Endocrinologists only )

DEXA studies, bone densitometry Ultrasonic guidance for needle biopsy Thyroid ultrasound

Gastroenterologists 76975* Endoscopic ultrasound Hand Surgeons 76000 Fluorscopies

Infertility Specialists Reproductive Endocrinologists Maternal and Fetal Medicine

76092 76805-76857 76930, 76941,76945, 76946 76075, 76076 76948

Screening Mammography Ultrasounds-pelvis Ultrasonic guidance DEXA studies, bone densitometry Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation.

Ob/Gyns

76075, 76076 76092 76815***, 76816***, 76830***, 76856, 76857 76930, 76941,76945, 76946

DEXA studies, bone densitometry Screening Mammography Ultrasounds-pelvis Ultrasounds-pelvis Ultrasonic guidance

AIUM/ACR Accredited Ob/Gyns 76805***, 76810***, 76818***, 76819***, 76825***, 76826***, 76827***, 76828***

Ultrasounds-pelvis

Oral surgeons 70100, 70110, 70140, 70150 70300, 70310, 70320 70328, 70330 70350 70355

Mandible and facial bone imaging Teeth imaging TMJ imaging Cephalogram, orthodontic Orthopantogram

Orthopedists G0188 (Orthopedic Surgeons) 71100-71111 71120-71130 72010-72120,72170, 72190, 72200-72220 73000-73140, 73500-73660 76000, 76003 76006 76040 76066

Full length radiography of lower extremity Radiologic examination, ribs Radiologic examination, sternum Spine and Pelvis imaging � � � � Imaging- Upper and lower extremities Fluroscopies Radiologic examination, any joint Bone length studies Joint survey

Pain Management Specialists(physiatrists, anesthesiologists, neurologists, and neurosurgeons)

76000 76005

Fluroscopies

Pediatricians 71010-71030 Chest imaging Perinatologists 76092

76805-76857 76930, 76945, 76946 76941

Screening mammography Ultrasounds-pelvis Ultrasonic guidance Ultrasonic guidance

Podiatrists 73620, 73630, 73650, 73660 Lower extremity imaging Pulmonologists 71010-71030 Chest Imaging Radiation oncologists 76950

76965 76370 76873

Ultrasonic guidance for placement of radiation therapy fields Ultrasonic guidance for interstitial radioelement application Computerized tomography guidance Determinate of prostate volume for brachy therapy

Rheumatologists G0188 72010-72120,72170, 72190,

Full length radiography of lower extremity Spine and pelvis imaging

72200-72220 73000-73140, 73500-73660 76000, 76003 76040, 76066 76075, 76076

� � � � Imaging- Upper and lower extremities Fluroscopies Bone length studies, joint survey DEXA studies, bone densitometry

Urologists 76870, 76872, G0050 76942

Ultrasounds � echography, genitalia, bladder Ultrasonic guidance for needle biopsy

Imaging Requiring PrecertificationImaging Requiring PrecertificationImaging Requiring PrecertificationImaging Requiring Precertification NYMI Pre-certification Policy for Urgent Cases: It is the responsibility of the imaging facility to confirm that a certification number has been issued prior to providing a service. In the case of examinations deemed urgent, in which there was no time to obtain a certification number and in cases in which, in the opinion of the rendering physician, a change is required from the certified examination, the study(ies) may be performed, and a new or modified certification number requested. The request for such a number must be made within two (2) business days of the date of service and must be made through the Imaging Care Management department in standard fashion. The clinical justification for the request will be reviewed using the same criteria as a routine request. NYMI Utilization Review Process: The utilization review process included matching the patient clinical history and diagnostic information with the approved criteria for each imaging procedure requested. Utilization review decisions are made by qualified health professionals including Board Certified Radiologists. Data collection for clinical certification of imaging services may be assigned to non-medical personnel working under the direction of qualified health professionals. Notification of review determinations for non-urgent care will be given by telephone to the requesting provider within two (2) working days of receipt of all the necessary information and within three (3) hours for a determination involving an urgent request. Requests for retrospective clinical certification review of medically urgent care will be accepted up to two (2) working days after the care has been rendered. Retrospective review decisions are made within thirty (30) working days of receiving all of the necessary information. In the event that the request is not authorized, the review determination will be given to the member and the requesting physician in writing within five (5) working days of making the decision. Below is a list of the imaging CPT codes that require pre-certification for commercial and Medicare Members. Please note that other procedures may be added as necessary; Oxford will inform you of all changes through the quarterly Program & Policy Update publication. To pre-certify a procedure, please call NYMI at 1-877-PRE-AUTH (1-877-773-2884). When calling the New York Medical Imaging Pre-certification unit, please provide the following information: Patient Identifiers:

• ID number and health plan• Name• Date of birth• Address

Medical Identifiers:• The ordering doctor’s name and address• The facility to which the patient is being referred, and its address.

• The contact person at your office

Clinical Information:• The examination(s) being requested, with CPT codes if available• The presumptive diagnosis or “rule out.” ICD codes if available• The patients signs and symptoms, listed in some detail, with severity and duration• Any treatments that have been tried, including dosage and duration for drugs and dates

for other therapies• Any other information that the doctor believes will help in evaluating the request, this

may include prior diagnostic tests, consultation reports, etc.

All authorization numbers are issued at the time of approval. When an authorization is issued by NYMI, the procedure authorized is incorporated into the authorization number. The authorized CPT code will be the last 5 digits in the authorization number. Please provide this number to the imaging provider whenscheduling the procedure. Clinical notes must be submitted for specific procedures: We have amended the pre-certification process to require the submission of clinical office notes for specific procedures. Clinical notes include the patient�s medical record and/or letters received from specialists that note: (a) patient symptoms, with duration and severity; (b) patient medical history; (c) previous imaging studies and findings; (d) prior treatment and/or therapy, including surgery, with history; and (e) drug dosage prescribed and duration. All information, including the request form, should be faxed to NYMI at 1-845-298-1490 ** These studies require the submission of clinical notes to NYMI (Note: not to supersede any exceptions set forth by Oxford Health Plans). CT SCANS CPT CODE CLINICAL

NOTES REQUIRED

DESCRIPTION

70450 CT HEAD/BRAIN W/O CONTRAST 70460 CT HEAD/BRAIN W/CONTRAST 70470 CT HEAD/BRAIN W/O AND W/CONTRAST 70480 CT ORBIT W/O CONTRAST 70481 CT ORBIT W/CONTRAST 70482 CT ORBIT W/O AND W/CONTRAST 70486 CT MAXLLFCL W/O CONTRAST 70487 CT MAXLLFCL W/CONTRAST 70488 CT MAXLLFCL W/O AND W/CONTRAST 70490 CT SOFT TISSUE W/O CONTRAST

CT Scans cont�d CPT CODE CLINICAL

NOTES REQUIRED

DESCRIPTION

70491 CT SOFT TISSUE W/CONTRAST 70492 CT SOFT TISSUE W/O AND W/CONTRAST 70496 CT ANGIOGRAPHY, HEAD 70498 CT ANGIOGRAPHY, NECK

71250 CT THORAX W/O CONTRAST 71260 CT THORAX W/ CONTRAST 71270 CT THORAX W/O AND W/CONTRAST 71275 CT ANGIOGRAPHY CHEST 72125 CT C SPINE W/O CONTRAST 72126 CT C SPINE W/ CONTRAST 72127 CT C SPINE W/O AND W/CONTRAST 72128 CT T SPINE W/O CONTRAST 72129 CT T SPINE W/CONTRAST 72130 CT T SPINE W/O AND W/CONTRAST

**72131 YES CT L SPINE W/O CONTRAST **72132 YES CT L SPINE W/CONTRAST **72133 YES CT L SPINE W/O AND W/CONTRAST 72191 CT ANGIOGRAPHY PELVIS 72192 CT PELVIS W/O CONTRAST 72193 CT PELVIS W/CONTRAST 72194 CT PELVIS W/O AND W/CONTRAST 73206 CT ANGIOGRAPHY UPPER EXTREMITY 73200 CT UPPER EXTREMITY W/O CONTRAST 73201 CT UPPER EXTREMITY W/CONTRAST 73202 CT UPPER EXTREMITY W/O AND W/CONTRAST 73700 CT LOWER EXTREMITY W/O CONTRAST 73701 CT LOWER EXTREMITY W/CONTRAST 73702 CT LOWER EXTREMITY W/O AND W/CONTRAST 73706 CT ANGIOGRAPHY LOWER EXTREMITY

74150 CT ABDOMEN W/O CONTRAST 74160 CT ABDOMEN W/CONTRAST 74170 CT ABDOMEN W/O AND W/CONTRAST 74175 CT ANGIOGRAPHY ABDOMEN 75635 CT ANGIOGRAPHY ABDOMINAL AORTA 76013 XRAY SUPERVISION AND INTPRETATION,

PERCUTANEOUS VERTEBRALPLASTY PER VERTEBRAL BODY UNDER CT GUIDANCE

76362 CT GUIDANCE FOR AND MONITORING OF TISSUE ABLATION

76380 CT LIMITED OR LOCALIZED FOLLOW-UP STUDY

MRI* (All MRI procedures require ACR accreditation) Note: Not to supersede any exceptions set forth by Oxford Health Plans

CPT CODE

CLINICAL NOTES

REQUIRED

DESCRIPTION

70336 MRI TMJ 70540 MRI FACE, ORBIT, NECK W/O CONTRAST 70542 MRI FACE, ORBIT, NECK WITH CONTRAST 70543 MRI FACE, ORBIT, NECK W/ & W/O CONTRAST 70551 MRI HEAD W/O CONTRAST

**70552 YES MRI HEAD W/CONTRAST **70553 YES MRI HEAD W/ & W/O CONTRAST 71550 MRI CHEST W/O CONTRAST 71551 MRI CHEST W/ CONTRAST 71552 MRI CHEST W/ & W/O CONTRAST

**72141 YES MRI CERVICAL SPINE W/O CONTRAST **72142 YES MRI CERVICAL SPINE W/CONTRAST **72146 YES MRI THORACIC SPINE W/O CONTRAST **72147 YES MRI THORACIC SPINE W/CONTRAST **72148 YES MRI LUMBAR SPINE W/O CONTRAST **72149 YES MRI LUMBAR SPINE W/CONTRAST **72156 YES MRI C SPINE W/ & W/O CONTRAST **72157 YES MRI T SPINE W/ & W/O CONTRAST **72158 YES MRI L SPINE W/ & W/O CONTRAST 72195 MRI PELVIS W/O CONTRAST 72196 MRI PELVIS W/CONTRAST 72197 MRI PELVIS W/ & W/O CONTRAST

**73218 YES MRI UPPER EXTREMITY OTHER THAN JOINT W/O CONTRAST

**73219 YES MRI UPPER EXTREMITY OTHER THAN JOINT W/ CONTRAST

**73220 YES MRI UPPER EXTREMITY OTHER THAN JOINT W/ & W/O CONTRAST

**73221 YES MRI UPPER EXTREMITY JOINT W/O CONTRAST **73222 YES MRI UPPER EXTREMITY JOINT W/ CONTRAST **73223 YES MRI UPPER EXTREMITY JOINT W/ & W/O CONTRAST **73718 YES MRI LOWER EXTREMITY OTHER THAN JOINT W/O

CONTRAST **73719 YES MRI LOWER EXTREMITY OTHER THAN JOINT W/

CONTRAST **73720 YES MRI LOWER EXTREMITY OTHER THAN JOINT W/ & W/O

CONTRAST **73721 YES MRI LOWER EXTREMITY JOINT W/O CONTRAST **73722 YES MRI LOWER EXTREMITY JOINT W/ CONTRAST **73723 YES MRI LOWER EXTREMITY JOINT W & W/O CONTRAST 74181 MRI ABDOMEN W/O CONTRAST 74182 MRI ABDOMEN W/ CONTRAST 74183 MRI ABDOMEN W/ & W/O CONTRAST

75552 CARDIAC MRI FOR MORPHOLOGY W/O CONTRAST (GATED HEART)

75553 CARDIAC MRI MORPHOLOGY W/CONTRAST 75554 CARDIAC MRI COMPLETE W/ OR W/O MORPHOLOGY

75555 CARDIAC MRI LIMITED 75556 CARDIAC MRI VELOCITY FLOW 76093 MRI BREAST W/ AND/OR W/O CONTRAST 76094 MRI BREAST BILATERAL 76390 MRI SPECTROSCOPY 76393 MRI GUIDANCE FOR PLACEMENT RADIOLOGICAL

SUPERVISION AND INTERPRETATION 76394 MRI GUIDANCE FOR T 76400 MRI BONE MARROW BLOOD SUPPLY 76499 Unlisted procedure

MRA* CPT

CODE DESCRIPTION

70544 MRA HEAD W/O CONTRAST 70545 MRA HEAD W/ CONTRAST 70546 MRA HEAD W/ & W/O CONTRAST 70547 MRA NECK W/O CONTRAST 70548 MRA NECK W/ CONTRAST 70549 MRA NECK W/ & W/O CONTRAST 71555 MRA CHEST (EXC MYOCARDIUM) W/ OR W/O CONTRAST 72159 MRA SPINAL CANAL W/ OR W/O CONTRAST 72198 MRA PELVIS W/ OR W/O CONTRAST 73225 MRA UPPER EXTREMITY W/ OR W/O CONTRAST 73725 MRA LOWER EXTREMITY W/ OR W/O CONTRAST 74185 MRA ABDOMEN W/ OR W/O CONTRAST

PET SCANS (CLINICAL NOTES ARE REQUIRED FOR ALL PET SCANS)

CPT CODE

CLINICAL NOTES

REQUIRED

DESCRIPTION

**78459 YES MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) METABOLIC EVAL.

**78491 YES MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; SINGLE STUDY AT REST OR STRESS

**78492 YES MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; MULTIPLE STUDIES AT REST OR STRESS

**78608 YES BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) METABOLIC EVALUATION

**78609 YES BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) METABOLIC EVALUATION, PERFUSION EVALUATION

**78810 YES TUMOR IMAGING (PET SCAN)

**G0030

YES PET MYOCARDIAL PERFUSION IMAGING;(FOLLOWING PREVIOUS PET, G0030-G0047); SINGLE STUDY, REST OR STRESS

Pet Scan cont�d **G0031 YES PET MYOCARDIAL PERFUSION IMAGING;(FOLLOWING

PREVIOUS PET, G0030-G0047); MULTIPLE STUDIES, REST OR STRESS

**G0032 YES PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING REST SPECT, 78464); SINGLE STUDY, REST OR STRESS

**G0033 YES PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING REST SPECT, 78464); MULTIPLE STUDIES, REST OR STRESS

**G0034 YES PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING SPECT, 78465); SINGLE STUDY, REST OR STRESS

**G0035 YES PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING SPECT, 78465); MULTIPLE STUDIES, REST OR STRESS

**G0036 YES PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING CORONARY ANGIOGRAPHY, 93510-93529); SINGLE STUDY, REST OR STRESS

**G0037 YES PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING CORONARY -ANGIOGRAPHY, 93510-93529); MULTIPLE STUDIES, REST OR STRESS

**G0038 YES PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING STRESS PLANAR MYOCARDIAL PERFUSION, 78460); SINGLE STUDY, REST OR STRESS

**G0040 YES PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING STRESS ECHOCARDIOGRAM, 93350); SINGLE STUDY, REST OR STRESS

**G0041 YES PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING STRESS ECHOCARDIOGRAM, 93350); MULTIPLE STUDIES, REST OR STRESS

**G0042 YES PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING STRESS NUCLEAR VENTRICULOGRAM, 78481 OR 78483); SINGLE STUDY, REST OR STRESS

**G0043 YES PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING STRESS NUCLEAR VENTRICULOGRAM, 78481 OR 78483); MULTIPLE STUDIES, REST OR STRESS

**G0044 YES PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING REST ECG, 93000); SINGLE STUDY, REST OR STRESS

**G0045 YES PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING REST ECG, 93000); MULTIPLE STUDIES, REST OR STRESS

**G0046 YES PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING STRESS ECG, 93015); SINGLE STUDY, REST OR STRESS

**G0047 YES PET MYOCARDIAL PERFUSION IMAGING, (FOLLOWING STRESS ECG, 93015); MULTIPLE STUDIES, REST OR STRESS

**G0125 YES PET LUNG IMAGING OF SOLITARY PULMONARY NODULES, USING 2-(FLUORINE-18)-FLUORO-2-DEOXY-D-GLUCOSE (FDG), FOLLOWING CT (71250/71260 or 71270)

**G0210 YES PET IMAGING WHOLE BODY; DIAGNOSIS; LUNG CANCER, NON-SMALL CELL

**G0211 YES PET IMAGING WHOLE BODY; INITIAL STAGING; LUNG

CANCER, NON-SMALL CELL **G0212 YES PET IMAGING WHOLE BODY; RESTAGING; LUNG CANCER,

NON-SMALL CELL **G0213 YES PET IMAGING WHOLE BODY; DIAGNOSIS; COLORECTAL

CANCER **G0214 YES PET IMAGING WHOLE BODY; INITIAL STAGING; COLORECTAL

CANCER **G0215 YES PET IMAGING WHOLE BODY; RESTAGING; COLORECTAL

CANCER **G0216 YES PET IMAGING WHOLE BODY; DIAGNOSIS; MELANOMA **G0217 YES PET IMAGING WHOLE BODY; INITIAL STAGING; MELANOMA **G0218 YES PET IMAGING WHOLE BODY; RESTAGING; MELANOMA **G0219 YES PET IMAGING WHOLE BODY; FULL AND PARTIAL RING PET

SCANNERS ONLY, NON COVERED INDICATIONS **G0220 YES PET IMAGING WHOLE BODY; DIAGNOSIS; LYMPHOMA **G0221 YES PET IMAGING WHOLE BODY; INITIAL STAGING; LYMPHOMA **G0222 YES PET IMAGING WHOLE BODY; RESTAGING; LYMPHOMA **G0223 YES PET IMAGING WHOLE BODY OR REGIONAL; DIAGNOSIS;

HEAD AND NECK CANCER; EXCLUDING THYROID AND CNS CANCERS

**G0224 YES PET IMAGING WHOLE BODY OR REGIONAL; INITIAL STAGING; HEAD AND NECK CANCER; EXCLUDING THYROID AND CNS CANCERS

**G0225 YES PET IMAGING WHOLE BODY OR REGIONAL; RESTAGING; HEAD AND NECK CANCER; EXCLUDING THYROID AND CNS CANCERS

**G0226 YES PET IMAGING WHOLE BODY; DIAGNOSIS; ESOPHAGEAL CANCER

**G0227 YES PET IMAGING WHOLE BODY; INITIAL STAGING; ESOPHAGEAL CANCER

**G0228 YES PET IMAGING WHOLE BODY; RESTAGING; ESOPHAGEAL CANCER

**G0229 YES PET IMAGING; METABOLIC BRAIN IMAGING FOR PRE-SURGICAL EVALUATION OF REFRACTORY SEIZURES

**G0230 YES PET IMAGING; METABOLIC ASSESSMENT FOR MYOCARDIAL VIABILITY FOLLOWING INCONCLUSIVE SPECT STUDY

**G0231 YES PET, WHOLE BODY, FOR RECURRENCE OF COLORECTAL METASTATIC CANCER; GAMMA CAMERAS ONLY

**G0232 YES PET, WHOLE BODY FOR RECURRENCE OF LYMPHOMA; GAMMA CAMERAS ONLY

**G0233 YES PET, WHOLE BODY, FOR RECURRENCE OF MELANOMA; GAMMA CAMERAS ONLY

**G0234 YES PET, REGIONAL OR WHOLE BODY, FOR SOLITARY PULMONARY NODULE FOLLOWING CT OR FOR INITIAL STATING OF PATHOLOGICALLY DIAGNOSED NON SMALL CELL LUNG CANCER; GAMMA CAMERAS ONLY

NUCLEAR MEDICINE CPT

CODE DESCRIPTION

78000 THYROID RAI UPTAKE 78001 THYROID, MULTIPLE UPTAKES 78003 THYROID SUPPRESS OR STIMULATION 78006 THYROID UPTAKE AND SCAN 78007 THYROID, IMAGE, MULTIPLE UPTAKES 78010 THYROID SCAN ONLY 78011 THYROID IMAGING WITH FLOW 78015 THYROID MET IMAGING 78016 THYROID MET IMAGING WITH ADDITIONAL STUDIES 78018 THYROID SCAN WHOLE BODY 78020 THYROID CARCINOMA METASTASES UPTAKE 78070 PARATHYROID NUCLEAR IMAGING 78075 ADRENAL NUCLEAR IMAGING 78099 UNLISTED ENDOCRINE PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE 78102 BONE MARROW IMAGING, LIMITED 78103 BONE MARROW IMAGING, MULTIPLE 78104 BONE MARROW IMAGING, WHOLE BODY 78110 PLASMA VOLUME, SINGLE 78111 PLASMA VOLUME, MULTIPLE SAMPLING 78120 RED CELL VOLUME DETERMINATION, SINGLE SAMPLING 78121 RED CELL VOLUME DETERMINATION, MULTIPLE SAMPLING 78122 WHOLE BLOOD VOLUME DETERMINATION, SEP PLASMA & RED CELL 78130 RED CELL SURVIVAL STUDY 78135 DIFFERENTIAL ORGAN / TISSUES KINETIC 78140 LABELED RED CELL SEQUESTRATION 78160 PLASMA RADIOIRON DISAPEARANCE 78162 RADIOIRON ORAL ABSORPTION 78170 RED CELL IRON UTILIZATION 78172 TOTAL BODY IRON ESTIMATION 78185 SPLEEN IMAGING W & W/O VAS FLOW 78190 PLATELET SURVIVAL, KINETICS 78191 PLATELET SURVIVAL 78195 LYMPH SYSTEM IMAGING 78199 UNLISTED HEMATOPOIETIC DIAGNOSTIC NUCLEAR MED 78201 LIVER IMAGING 78202 LIVER IMAGING WITH FLOW 78205 LIVER IMAGING SPECT (3-D) 78206 LIVER IMAGING SPECT W/ VASCULAR FLOW 78215 LIVER & SPLEEN IMAGING 78216 LIVER & SPLEEN IMAGING WITH FLOW 78220 LIVER FUNCTION STUDY 78223 HIDA SCAN 78230 SALIVARY GLAND IMAGING 78231 SERIAL SALIVARY GLAND 78232 SALIVARY GLAND FUNCTION EXAM 78258 ESOPHOGUS MOTILITY STUDY

78261 GASTRIC MUCOSA IMAGING 78262 GASTROESOPHAGEAL REFLUX EXAM 78264 GASTRIC EMPTYING STUDY 78270 VIT-B12 ABSORPTION EXAM 78271 VIT-B12 ABSORPTION EXAM, LF 78272 VIT-B12 ABSORPTION EXAM COMBINED 78278 GI BLEEDER SCAN 78282 GI PROTEIN LOSS EXAM 78290 MECKEL�S DIVERTICULUM IMAGING 78291 LEVEEN SHUNT PATENCY EXAM 79299 UNLISTED GASTROINTESTINAL 78300 BONE OR JOINT IMAGING LTD 78305 BONE OR JOINT IMAGING MULTIPLE 78306 BONE SCAN WHOLE BODY 78315 BONE SCAN 3-PHASE STUDY 78320 BONE JOINT IMAGING TOMO TEST 78399 UNLISTED MUSCULOSKELETAL 78414 NON-IMAGING HEART FUNCTION 78428 CARDIAC SHUNT IMAGING 78445 RADIONUCLIDE VENOGRAM NON-CARDIAC 78455 VENOUS THROMBOSIS STUDY 78456 ACUTE VENOUS THROMBOSIS IMAGING 78457 VENOUS THROMBOSIS IMAGING UNILATERAL 78458 VENOUS THROMBOSIS IMAGES, BILATERAL 78460 THALLIUM SCAN REST ONLY 78461 MYOCARDIAL PERF STRESS OR REST MULTIPLE STUDY 78464 HEART IMAGE (3-D) SINGLE 78465 MYOCARDIAL PERF W/SPECT MULTIPLE 78466 MYOCARDIAL INFARCTION SCAN 78468 HEART INFARCT IMAGE EF 78469 HEART INFARCT IMAGE 3-D 78472 GATED HEART, RESTING 78473 CARDIAC BLOOD POOL MUGA SCAN 78478 MYOCARDIAL WALL MOTION STUDY 78481 HEART FIRST PASS SINGLE 78483 CARDIAC BLOOD POOL IMAGING � MULTIPLE 78494 CARDIAC BLOOD POOL IMAGING, SPECT 78496 CARDIAC BLOOD POOL IMAGING � SINGLE STUDY AT REST (USE WITH 78472) 78499 UNLISTED CARDIOVASCULAR NUCLEAR EXAM 78580 PULMONARY PERFUSION IMAGING 78584 PULMONARY PERFUSION WITH VENT SINGLE BREATH 78585 PULMONARY PERFUSION W/ WASHOUT, W/ OR W/O SINGLE BREATH 78586 PULMONARY VENTILATION IMAGING 78587 PULMONARY VENTILATION MULTI 78588 PULMONARY PERFUSION W/ VENTILATION 78591 VENT IMAGE 1 BREATH, 1 PROJECTION 78593 VENT IMAGE 1 PROJECTION, GAS 78594 VENT IMAGE MULTI PROJECTION, GAS 78596 LUNG DIFFERENTIAL FUNCTION 78599 UNLISTED RESPIRATORY NUCLEAR EXAM

78600 BRAIN IMAGING LTD STATIC 78601 BRAIN LTD IMAGING AND FLOW 78605 BRAIN IMAGING COMPLETE 78606 BRAIN IMAGING COMPLETE WITH FLOW 78607 BRAIN IMAGING 3-D 78610 BRAIN FLOW IMAGING ONLY 78615 CREBRAL BLOOD FLOW IMAGING 78630 CISTERNOGRAM (CEREBROSPINAL FLUID FLOW) 78635 CEREBROSPINAL VENTRICULOGRAPHY 78645 CSF SHUNT EVALUATION 78647 CEREBROSPINAL FLUID SCAN 78650 CSF LEAKAGE DETECTION AND LOCALIZATION 78660 RADIOPHARMACEUTICAL DACRYOCYSTOGRAPHY 78699 UNLISTED DIAGNOSTIC NUCLEAR MED PROCEDURE 78700 KIDNEY IMAGING (STATIC) 78701 KIDNEY IMAGING W/VASCULAR FLOW 78704 KIDNEY IMAGING W/FUNCTION STUDY 78707 KIDNEY IMAGING W/VASCULAR FLOW & FUNCTIONAL SINGLE STUDY 78708 KIDNEY IMAGING SINGLE STUDY W/PHARM. INTERVENTION 78709 KIDNEY IMAGING � MULTIPLE STUDIES W/ & W/O PHARM. INTERVENTION 78710 KIDNEY IMAGING � TOMOGRAPHIC (SPECT) 78715 KIDNEY VASCULAR FLOW ONLY 78725 KIDNEY FUNCTION STUDY � NON-IMAGING RADIOISOTOPIC 78730 URINARY BLADDER RESIDUAL STUDY 78740 URETERAL REFLUX STUDY 78760 TESTICULAR IMAGING 78761 TESTICULAR IMAGING W/VASCULAR FLOW 78799 UNLISTED GENITOURINARY PROCEDURE 78800 RADIOPHARM LOCALIZATION OF TUMOR, LIMITED AREA 78801 RADIOPHARM LOCALIZATION OF TUMOR, MULTIPLE AREAS 78802 RADIOPHARM LOCALIZATION OF TUMOR, WHOLE BODY 78803 RADIOPHARM LOCALIZATION OF TUMOR TOMOGRAPHIC (SPECT) 78805 RADIOPHARM LOCALIZATION OF ABSCESS, LIMITED AREA 78806 RADIOPHARM LOCALIZATION OF ABSCESS, WHOLE BODY 78807 RADIOPHARM LOCALIZTION OF ABSCESS, TOMOGRAPHIC SPECT 78999 UNLISTED MISC. PROCEDURE 79299 UNLISTED GASTRO PROCEDURE

OBSTETRICAL ULTRASOUNDS AUTHORIZATION REQUIRED FOR FOURTH (4+) AND SUBSEQUENT PROCEDURES(NOTE: 76805, 76810, 76818, 76819, 76825, 76826, 76827 AND 76828 ALL REQUIRE AIUM OR ACRACCREDITATION)

CPT CODE

DESCRIPTION

76805 ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME W/IMAGE DOCUMENTATION, COMPLETE FETAL AND MATERNAL EVALUATION

76810 COMPLETE-FETAL AND MATERNAL EVALUATION, MULTIPLE GESTATION, AFTER THE FIRST TRIMESTER

76815 LIMITED-FETAL SIZE, HEART BEAT, PLACENTAL LOCATION, FETAL POSITION OR EMERGENCY IN THE DELIVERY ROOM

76816 FOLLOW UP OR REPEAT 76818 FETAL BIOPHYSICAL PROFILE 76819 FETAL BIOPHYSICAL PROFILE; WITHOUT STRESS OR NON-STRESS TESTING 76825 ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, REAL TIME

W/IMAGE DOCUMENTATION (2D), W/ OR W/O M-MODE RECORDING 76826 FOLLOW UP OR REPEAT STUDY 76827 DOPPLER ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, PULSED

WAVE AND/OR CONTINUOUS WAVE W/SPECTRAL DISPLAY, COMPLETE 76828 FOLLOW UP OR REPEAT STUDY 76830 ECHOGRAPHY, TRANSVAGINAL C. PHYSICAL AND OCCUC. PHYSICAL AND OCCUC. PHYSICAL AND OCCUC. PHYSICAL AND OCCUPATIONAL THERAPYPATIONAL THERAPYPATIONAL THERAPYPATIONAL THERAPY OrthoNet, a musculoskeletal disease management company, is Oxford�s network manager for all commercial outpatient physical and occupational therapy services. OrthoNet is a local, provider-based company with ties to leading practitioners in Oxford�s service area. All commercial physical and occupational therapy services following initial evaluation CPT codes 97001 and 97003 require authorization by OrthoNet, excluding chiropractic care which will continue to be managed by Oxford. A referral is required for the initial evaluation (excluding non-gatekeeper Members). Please see the below list of CPT codes that require utilization review. Authorization requests can be made by faxing the necessary documentation to OrthoNet at 800-216-0810; responses will be communicated by fax. The target goal is to provide responses within 24 hours of receipt of all required clinical documentation. For PCPs, there has been no change made to the current Oxford referral process for the first therapy visit (CPT codes 97001 and 97003). Please simply refer the Member; do not indicate the number of visits for which the Member is approved, since that will be determined as part of the utilization review process. Note: Electronic referral receipts which show the number of visits, cannot be used in lieu of the OrthoNet program. All visits beyond the initial evaluations must still be precertified with OrthoNet regardless of the number of visits that may be listed on the electronic referral receipt. For providers of physical and occupational therapy, there are no changes to the existing claims submission process or the Oxford fee Schedule. Please be advised that failure to comply with the new medical management policy for therapy services after the initial evaluation may result in nonpayment. If you have any questions on how to get the necessary forms, please call OrthoNet�s Provider Services Department at 800-201-4891. CPT Codes Requiring OrthoNet AuthorizationCPT Codes Requiring OrthoNet AuthorizationCPT Codes Requiring OrthoNet AuthorizationCPT Codes Requiring OrthoNet Authorization CPT Description 97002 Physical therapy reevaluation 97004 Occupational therapy reevaluation 97010 Application of a modality� doesn�t require direct patient-provider contact, hot or cold packs 97012 Application of a modality� doesn�t require direct patient-provider contact, traction � mechanical 97014 Application of a modality� doesn�t require direct patient-provider contact, electrical stimulation

(unattended) 97016 Application of a modality� doesn�t require direct patient-provider contact, vasopneumatic devices 97018 Application of a modality� doesn�t require direct patient-provider contact, paraffin bath 97020 Application of a modality� doesn�t require direct patient-provider contact, microwave 97022 Application of a modality� doesn�t require direct patient-provider contact, whirlpool 97024 Application of a modality� doesn�t require direct patient-provider contact, diathermy

97026 Application of a modality� doesn�t require direct patient-provider contact, infrared 97028 Application of a modality� doesn�t require direct patient-provider contact, ultraviolet 97032 Application of a modality�requires direct patient-provider contact, electrical stimulation (manual) 97033 Application of a modality�requires direct patient-provider contact, iontophoresis 97034 Application of a modality�requires direct patient-provider contact, contrast baths 97035 Application of a modality�requires direct patient-provider contact, ultrasound 97036 Application of a modality�requires direct patient-provider contact, Hubbard tank 97039 Application of a modality�requires direct patient-provider contact, unlisted modality (specify) 97110 Therapeutic exercises to develop strength and endurance, range of motion and flexibility 97112 Neuromuscular reeducation of movement 97113 Aquatic therapy with therapeutic exercises 97116 Gait training (included stair climbing) 97124 Massage, including effleurage, petrissage and/or tapotement 97139 Unlisted therapeutic procedure (specify) 97140 Manual therapy techniques, one or more regions 97150 Therapeutic procedures, group (2 or more individuals) 97504 Orthotics, fitting and training, upper and/or lower extremities 97520 Prosthetic training, upper and/or lower extremities 97530 Therapeutic activities - direct patient-provider contact, use of dynamic activities to improve

functional performance 97535 Self care/home management training - direct patient-provider contact 97537 Community/work reintegration training - direct patient-provider contact 97542 Wheelchair management/propulsion training 97545 Work hardening/conditioning, initial 2 hours 97546 Work hardening/conditioning, each additional hour 97703 Checkout for orthotic/prosthetic use, established patient 97750 Physical performance test or measurement 97770 Development of cognitive skills to improve attention, memory, problem solving 97799 Unlisted physical medicine/rehabilitation service or procedure

D. PHARMACYD. PHARMACYD. PHARMACYD. PHARMACY Oxford�s pharmacy system is a comprehensive package of benefits, formularies, and management programs. These programs are updated as new drugs are approved, new indications for old drugs emerge, and new medical knowledge becomes available. Pharmacy Benefits ManagerPharmacy Benefits ManagerPharmacy Benefits ManagerPharmacy Benefits Manager Merck-Medco Managed Care L.L.C. is Oxford�s pharmacy benefits manager. Merck-Medco has a dedicated service line to address all physician questions. This line is available 24 hours a day seven days a week (excluding Thanksgiving and Christmas Day). The phone number for providers is 800-905-0201. ThreeThreeThreeThree----Tier Prescription Drug Benefit Tier Prescription Drug Benefit Tier Prescription Drug Benefit Tier Prescription Drug Benefit Oxford has a Three-Tier prescription drug benefit for some commercial and Medicare Plans. The Preferred Drug List for this benefit was carefully designed to promote medically appropriate, cost-effective healthcare while preserving your ability to prescribe specific agents of choice for your patients. The three tiers of this drug benefit include Generic drugs (tier 1), Preferred Brand drugs (tier 2), and non-preferred brand name drugs (tier 3), with an increase in copayment to our Members with each tier. Members covered by the Three-Tier

prescription plan benefit may have one of the following plan designs, depending on which benefit their employer has chosen: Plan Design* Tier 1:

Generic Drugs Tier 2:

Preferred Brand Drugs

Tier 3: Non-Preferred Brand

Name Drugs Rx Plan A copayments $5 $15 $35 Rx Plan B copayments $5 $15 $50 Rx Plan C copayments $7 $20 $50 Rx Plan D copayments $5 $10 $20 Rx Plan E copayments $7 $15 $35 Rx Plan F copayments $10 $20 $50

* Plan designs are not available in all states. Note: this is not a complete listing. Providers may continue to choose from among the many quality drugs available, using their patient�s out-of-pocket cost as a consideration when prescribing. We ask that you please review Oxford�s Preferred Drug List and, where appropriate for your patients, consider changing tier 3 prescriptions to Generic or Preferred Brand medications. The Preferred Drug List can be found at the end of this chapter. Oxford�s complete Prescription Drug Formulary can be found on Oxford�s web site www.oxfordhealth.com. Please note: This three-tier drug benefit structure may be extended to other groups. Please refer to the Program & Policy Update for any changes. Pharmacy Management ProgramsPharmacy Management ProgramsPharmacy Management ProgramsPharmacy Management Programs Together with Merck-Medco, our pharmacy benefit manager, we have established programs to help ensure that our Members receive drug therapy that is medically appropriate and economical. These programs are largely based on guidelines established by the Food and Drug Administration (FDA). Drug Utilization Review (DUR) and Quantity Limits Today, pharmacists submit almost all prescriptions electronically. Within seconds, the Member�s claim registers and the medical records for the past six months are reviewed searching for potential drug related problems. Examples include drug interactions, inappropriate drug dosage, and drugs that should be used with caution during pregnancy. In many cases, the limitation reflects the maximum FDA-recommended dosage for a drug or the most efficient pill size for the fully prescribed daily dose. In these situations, an electronic message specifying a quantity level limit will be sent to the pharmacist instructing that the prescription be reviewed with you. In all cases, the goal is to encourage medically appropriate and economic use of drugs. Physician Utilization Reports These programs are designed to provide physicians with information regarding their prescription patterns for certain therapeutic classes of medication. By accumulating, analyzing, and interpreting information about prescription drugs used by our Members, Oxford provides a customized profile that can be used by each physician to monitor his or her prescribing habits in relation to recommended guidelines, national norms, and peers in the community. The goal of the program is to improve future prescribing practices. Utilization Management Programs Using the correct dosage of the appropriate drug for the right length of time to treat a patient�s medical condition is key to providing appropriate pharmacy care. For some of the most important chronic

conditions, guidelines for diagnosis and treatment have been established by the FDA and other government and medical subspecialty societies. To promote appropriate utilization, selected medications require prior authorization to be eligible for coverage. Drugs requiring prior authorization must meet clinical criteria established by Oxford�s Pharmacy & Therapeutic (P&T) Committee. For drugs in this category, there may be other drugs that might first be used as part of step therapy, or the drug may act as a flag to bring other resources of the organization to the management of a Member. Prior Authorization Programs To obtain prior authorization, you should call 1-800-753-2851, Monday through Friday, 8 AM to 9 PM EST. Prior authorization representative will gather the information needed to meet criteria for approval of the drug or send the information to an Oxford Medical Director for further evaluation. If the Medical Director does not approve the request, you will be notified by phone and will have an opportunity to provide additional information for review. Anabolic steroids* • Androderm Patches • Anadrol � 50 • Androgel • Android • Deca Durabolin • Depo Testosterone • Halotestin • Methyltestosterone • Oxandrin • Testoderm • Testosterone • Winstrol CNS stimulants • Adderall1 • Concerta1 • Dexedrine1 • Desoxyn1 • Dextrostat1

Acne medications • Avita2 • Differin2 • Retin A2

Proton pump inhibitors* • Aciphex • Nexium • Prevacid • Prilosec • Protonix Impotence drugs** • Viagra Arthritis medications • Celebrex* • Enbrel • Vioxx* • Kineret • Bextra

Specialized OB/GYN drugsSpecialized OB/GYN drugsSpecialized OB/GYN drugsSpecialized OB/GYN drugs • Lupron (3.75 mg & 11.25 mg) Misc. Medications

• Nutritional Therapies • Phoslo • Serostim • Vitamin D preparations (i.e. Hectorol,

Rocaltrol, etc.)

1Applies only to Members 19 years of age or older. 2Applies only to Members 40 years of age or older.

*Precertification is not required for Oxford Medicare Advantage Members.**Medication is not covered for Oxford Medicare Advantage Members

Please note: Precertification requirements may vary, depending on the Members benefit. For the most up-to-date information, please call Pharmacy Customer Service at 800-905-0201.

Quality Management Program: Controlled Drug Use Evaluation (DUE) The objective of DUE is to promote medically appropriate drug therapy for our patients. On a quarterly basis, Oxford reviews the medication profiles of Members who receive frequent prescriptions for narcotic analgesics and other controlled drugs at high doses. Members are selected for review if they received 12 or more controlled drugs during a three month period, at an average daily dose of 10 or more dosage units per day, or received prescriptions from three or more physicians. If any patients for whom you prescribe controlled drugs meet these criteria, you will be notified by mail. The intention of this letter is to provide information and, when indicated (in your opinion), facilitate action toward modifying your patient�s drug use behavior. Please review this information carefully if you are contacted. Mail Order Through MerckMail Order Through MerckMail Order Through MerckMail Order Through Merck----MedcoMedcoMedcoMedco Merck-Medco Home Delivery Pharmacy ServicesTM is also Oxford�s mail-order prescription drug manager through which eligible Members can receive a 90-day supply of certain maintenance medications. All Members whose plans include the mail-order benefit are entitled to use Merck-Medco mail-order service. Merck-Medco Home Delivery Pharmacy ServicesTM P.O. Box 747000 Cincinnati, OH. 45274-7000 If your Oxford patients have any questions about their benefits or maintenance prescription medications, Members they can call Oxford�s Pharmacy Customer Service line at 800-905-0201, 24 hours a day, seven days a week. (excluding Thanksgiving and Christmas Day). The Prescription Drug FormularyThe Prescription Drug FormularyThe Prescription Drug FormularyThe Prescription Drug Formulary The formulary is a dynamic listing of medications that is reviewed at least annually and updated quarterly to reflect advances in medical care. The Pharmacy and Therapeutics Committee (P&T), which consists of Oxford�s participating physicians, Medical Directors, and pharmacists, is responsible for developing and maintaining Oxford�s Prescription Drug Formulary. The P&T quarterly updates will appear in the Program & Policy Update. Formulary inclusion, relative cost index, generic drug policy, drug quantity limit and prior authorization programs are delineated in the drug formulary, which is available on our web site www.oxfordhealth.com. Please note that the listing of a drug product does not guarantee coverage as certain products are excluded due to benefit plan design limitations that are specific to Member�s individual or group benefits. The following Preferred Drug List is a partial list , which includes more than 700 generic and brand name drugs. The list is alphabetized by the name of the drug. Generic drugs are listed in lower case letters. preferred brand drugs are listed in CAPITAL letters. If a drug is not listed, it is a non-preferred Brand drug and subject to the three-tier pharmacy benefit (if the Member has a three-tier benefit). This list of drugs is subject to changes and changes will be posted in the quarterly Program and Policy Update. Drugs affected by quantity limits are designated by an asterisk (*). Drugs requiring prior authorization are designated as (PAR). The Preferred Drug List ACCUPRILACCURETICACCUTANEacebutololacetaminophen/butalbitalacetaminophen/caffeine/butalbacetazolamide

acetic acidacetic acid/aluminum acetateacetic acid/hydrocortisoneacetylcysteineACULAR/PFacyclovir*ADVAIR

AGENERASEAGRYLINALBENZA*albuterol inhaleralbuterol (tablet, solution)ALDARAALESSE

ALKERAN*ALLEGRA*ALLEGRA-DallopurinolALPHAGANalprazolamamantadine*AMERGEAMICARamilorideamiloride/HCTZaminocaproic acidaminophyllineamiodaroneamitriptylineamitriptyline hcl/perphenazineamitriptyline/chlordiazepoxideamoxapineamoxicillinampicillin*ANA-GUARD*ANA-KITANDRODERM (PAR)ANDROGEL (PAR)antipyrine/benzocaineapap/isometheptene/dichlphenARICEPTARIMIDEXAROMASINASACOLaspirin/caffeine/butalbitalatenololatropine sulfateATROVENT inhAUGMENTINAVANDIAAVCAVELOX*AVONEX (PAR)AYGESTINazathioprine*AZMACORTAZOPTbacitracin ophthalmicbaclofenBACTROBAN CREAMBACTROBAN OINTMENT*BECONASEBECONASE AQbelladonna alkaloids/phenobarbbenzene hexachloride gammabenztropinebetamethasone dipropionatebetamethasone valerate*BETASERONbethanechol

BETOPTIC/SBILTRICIDEbisoprolol fumarate/HCTZBLEPHAMIDEbromocriptine mesylatebumetanidebupropion immediate releasebuspironeCAFERGOTCAPITROL SHAMPOOcaptoprilcaptopril/hctzcarbamazepineCARBATROLcarbidopa/levodopacarisoprodolCASODEX*CATAPRESS TTSCEENUcefaclorcefadroxilCEFTIN (susp only)CELLCEPTCELONTINcephalexincephradineCERUMENEXCHEMETCHILDREN’S ADVILchloral hydratechlordiazepoxide hclchlorhexidineCHLOROMYCETIN OTICchloroquine phosphatechlorothiazidechlorpromazinechlorpropramidechlorthalidonechlorthalidone/atenololchlorzoxazonechol sal/magnesium salicylatecholestyramine/aspartamecholestyramine/sucrosecimetidineCIPRO .CLARITIN (Tabs non-preferred,only syrup preferred AND <12y.o.)CLEOCIN VAGINALclidinium/chlordiazepoxide*CLIMARAclindamycinclobetasol propionateclomipramineclonazepamclonidine tablet

clonidine hcl/chlorthalidoneclorazepateclotrimazoleclozapinecodeine phosphatecodeine phosphate/apapcodeine phosphate/aspirincodeine sulfatecodeine/apap/caffeine/butalbcolchicineCOLYTECOMBIVIRCOMTANCONDYLOX*COPAXONECORDRAN/SPCOREGCORTENEMACORTIFOAMCOTAZYM/SCOUMADINCOZAARCREONCRIXIVANcromolyn nebulizer solutionCUPRIMINEcyclobenzaprinecyclopentolatecyproheptadineCYTADRENCYTOTECCYTOVENECYTOXANdanazolDANTRIUMdantroleneDAPSONEDARAPRIMDDAVPDENAVIRDEPAKENEDEPAKOTEDEPEN TITRATABSDERMA-SMOOTHE/FS 0.01%desipraminedesonideDESOWEN LOTIONdesoximetasoneDESQUAM-Xdexamethasonedexamethasone sod phosphate*DIASTATdiazepamDIBENZYLINEdiclofenac potassiumdiclofenac sodium

dicloxacillindicyclominediethylstilbestrol diphosphatediflorasoneDIFLUCAN*DIFLUCAN 150MG TABdiflunisaldigoxinDILANTINDILAUDIDdiltiazemdiphenhydraminediphenoxylate/atropine sulfatedipivefrinDIPROSONE 0.1% top spraydipyridamoledisopyramidedisulfiramDOVONEXdoxazosindoxepindoxycycline hyclatedoxycycline monohydrateDRITHOCREMEDRITHO-SCALPDRYSOLDURAGESICDYNAPEN (susp only)EFFEXOREFFEXOR XREFUDEXELDOPAQUE FORTEELDOQUIN FORTE Rx*electrolyte solution/peg'sELMIRONEMCYTenalaprilENBREL (PAR)ENDEPEPIFRIN*EPIPEN/JREPIVIR HBV*EPIVIRERGAMISOLergoloid mesylatesERGOMARergotamine tartrate/caffeineergotamine/belladonna/pbERYPED SUSPENSIONerythromycin baseerythromycin ethylsuccinateerythromycin stearateerythromycin/sulfisoxazoleESKALITH CRestradiol tabletESTRATEST/HS

*ESTRINGestropipateESTROSTEP FEETHMOZINEetodolacEULEXINEURAXEVISTAfamotidineFANSIDARFARESTONFELBATOLFEMARAfenoprofenFIORICET WITH CODEINE #3*FLONASEFLORINEF ACETATE*FLOVENT*FLOVENT ROTADISKFLOXIN OTICfluocinolone acetonidefluocinonidefluorometholoneFLUOROPLEXfluoxetinefluoxymesterone (PAR)fluphenazine hclflurazepamflurbiprofenfluvoxamineFML-SFORTOVASE*FOSAMAXfurosemideFUROXONEGABITRILgemfibrozilgentamicingentamicin/prednisoloneglipizide immediate releaseGLUCAGONGLUCOPHAGE*GLUCOTROL XLglyburidegriseofulvin ultramicrosizeguanabenzguanfacineHALOG/EhaloperidolHALOTESTIN (PAR)HEXALENHIVIDhomatropine hbrHUMALOGHUMULIN 50/50HUMULIN 70/30

HUMULIN LHUMULIN NHUMULIN RHUMULIN Uhydralazinehydralazine/hctzhydrochlorothiazidehydrocodone bitartrate/apaphydrocortisonehydrocortisone acetatehydrocortisone valeratehydromorphonehydroquinonehydroxychloroquinehydroxyureahydroxyzine hclhydroxyzine pamoatehyoscyaminehyoscyamine sulfatehyoscyamine sulfate/phenobarbHYZAARibuprofenILETIN II REGULAR(PORK)ILETIN INSULINILETIN LENTE PORK ZINCILETIN NPH PORK ZINCILETIN REGULAR PORK ZINCimipramine hcl*IMITREXindapamideINDERAL LAindomethacinINSULIN LENTE PURIFIEDPORKINSULIN NPH PURIFIED PORKINSULIN REGULAR PURIFIEDPORKINVIRASEipratropium nebulizer solutionisoniazidISOPTO CARBACHOLisosorbide dinitrateisosorbide mononitrateisoxsuprineKALETRAketoconazoleketoprofenketorolac tabletKLARONK-LYTE/CL*KYTRILlabetalollactuloseLAMICTALLAMPRENELANOXIN

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