Procedures, programs and that require precertification

Participating provider precertification list

Starting June 1, 2021

Applies to the following plans (also see General information section #1-#4, #9-#10): Aetna® plans, except Traditional Choice® plans All health benefits and insurance plans offered and/or underwritten by Innovation Health plans, Inc., and Innovation Health Insurance Company, except indemnity plans, Foreign Service Benefit Plan, MHBP and Rural Carrier Benefit Plan

All health benefits and health insurance plans offered, underwritten and/or administered by the following: Banner Health and Aetna Health Insurance Company and/or Banner Health and Aetna Health Plan Inc. (Banner|Aetna), Texas Health +Aetna Health Insurance Company and/or Texas Health+Aetna Health Plan Inc. (Texas Health Aetna), Allina Health and Aetna Health Insurance Company (Allina Health| Aetna), Sutter Health and Aetna Administrative Services LLC (Sutter Health | Aetna)

Aetna.com

23.03.882.1 R (6/21)

For more information, read all general precertification guidelines Providers may submit most precertification requests electronically through the secure provider website or using your Electronic Medical Record (EMR) system portal. (See #1 in the General Information section for more information on precertification.)

Services that require precertification:

1. Inpatient confinements (except hospice) 18. Nonparticipating freestanding ambulatory For example, surgical and nonsurgical stays, surgical facility services, when referred by stays in a skilled nursing facility or rehabilitation a participating provider facility, and maternity and newborn stays that 19. Orthognathic surgery procedures, bone exceed the standard length of stay (LOS). (See grafts, osteotomies and surgical #6 in the General Information section.) management of the temporomandibular 2. Ambulance joint Precertification required for transportation by 20. Osseointegrated implant fixed- wing aircraft (plane) 21. Osteochondral allograft/knee 3. Arthroscopic hip surgery to repair impingement 22. Private duty nursing syndrome including labral repair 23. Proton beam radiotherapy 4. Autologous chondrocyte implantation Also see Special Programs; Radiation Oncology 5. Chiari malformation decompression surgery 24. Reconstructive or other procedures that maybe 6. Cochlear device and/or implantation considered cosmetic, such as: 7. Coverage at an in-network benefit level • Blepharoplasty/canthoplasty for out-of-network provider or facility • Breast reconstruction/breast enlargement unless services are emergent. • Breast reduction/mammoplasty Some plans have limited or no out-of­network • Excision of excessive skin due to weight loss benefits. • Gastroplasty/gastric bypass 8. Dental implants • Lipectomy or excess fat removal 9. Dialysis visits • Surgery for varicose veins, except stab phlebectomy When a participating provider initiates a 25. Shoulder Arthroplasty including revision request and dialysis is to be performed at a procedures nonparticipating facility. 26. Spinal procedures, such as: 10. Dorsal column (lumbar) neurostimulators: • Artificial intervertebral disc surgery (cervical spine) trial or implantation • Arthrodesis for spine deformity 11. Electric or motorized wheelchairs and • Cervical laminoplasty scooters • Cervical, lumbar and thoracic laminectomy and\or 12. Endoscopic nasal balloon dilation procedures laminotomy procedures 13. Functional endoscopic sinus surgery (FESS) • Kyphectomy 14. Gender affirmation surgery • Laminectomy with rhizotomy 15. Hyperbaric oxygen • Spinal fusion surgery 16. Infertility services and pre-implantation 27. Uvulopalatopharyngoplasty, genetic testing including laser- assisted procedures 17. Lower limb prosthetics, such as 28. Ventricular assist devices microprocessor-controlled lower limb 29. Video electroencephalograph (EEG) prosthetics 30. Whole exome sequencing

Proprietary

Drugs and medical injectables

Blood-clotting factors (precertification for outpatient infusion of this class is required)

For the following services, providers should call 1-855-888-9046 for precertification, with the following exceptions: • Precertification of pharmacy-covered specialty drugs − For the Foreign Service Benefit Plan, call Express Scripts at 1-800-922-8279 − For MHBP and the Rural Carrier Benefit Plan, call CVS Caremark® at 1-800-237-2767

Advate (antihemophilic factor, human recombinant) Ixinity (coagulation factor IX [recombinant]) Adynovate (antihemophilic factor [recombinant], Jivi [antihemophilic factor (recombinant), PEGylated) PEGylated-aucl] Afstyla (antihemophilic factor [recombinant],

single chain) Koate, Koate-DVI (antihemophilic factor [human]) Kogenate FS (antihemophilic factor [recombinant]) Alphanate (antihemophilic factor/von Willebrand Kovaltry (antihemophilic factor [recombinant]) factor complex [human]) Monoclate-P (antihemophilic factor [human]) AlphaNine SD (coagulation factor IX [human]) Mononine (coagulation factor IX [human]) Alprolix (coagulation factor IX [recombinant], Fc NovoEight (turoctocog alfa) fusion ) NovoSeven RT (coagulation factor VIIa [recombinant]) Bebulin (factor IX complex) Nuwiq (simoctocog alfa) BeneFix (coagulation factor IX [recombinant]) Obizur (antihemophilic factor [recombinant], Coagadex (coagulation factor X [human]) porcine sequence) Corifact (factor XIII concentrate [human]) Profilnine (factor IX complex) Eloctate (antihemophilic factor [recombinant], Fc Rebinyn (coagulation factor IX [recombinant], fusion protein) glycoPEGylated) Esperoct [antihemophilic factor (recombinant), Recombinate (antihemophilic factor [recombinant]) glycopegylated-exei] RiaSTAP (fibrinogen concentrate [human]) FEIBA, FEIBA NF (anti-inhibitor coagulant Rixubis (coagulation factor IX [recombinant]) complex) Sevenfact (coagulation factor VIIa [recombinant]­ Fibryga (fibrinogen, human) jncw) Helixate FS (antihemophilic factor [recombinant]) Tretten (coagulation factor XIII a-subunit Hemlibra (emicizumab-kxwh) [recombinant]) Hemofil M (antihemophilic factor [human]) Vonvendi (von Willebrand factor [recombinant]) Humate-P (antihemophilic factor/von Willebrand Wilate (von Willebrand factor/coagulation factor factor complex [human]) VIII complex [human]) Idelvion (antihemophilic factor [recombinant]) Xyntha, Xyntha Solof (antihemophilic factor [recombinant])

Proprietary

Other drugs and medical injectables For the following services, providers call 1-866-752-7021 for precertification and fax applicable request forms to 1-888-267-3277, with the following exceptions: • For precertification of pharmacy-covered specialty drugs (notedwith *) when the member is enrolled in a commercial plan, call 1-855-240-0535. Or fax applicable request forms to 1-877-269-9916. • Providers can use the drug-specific Specialty Request Form located online under “Specialty Pharmacy Precertification.” • Providers can submit Specialty Pharmacy precertification requests electronically using provider online tools and resources at our provider portal with Aetna. • See our Medicare online resources for more about preferred products or to find a precertification fax form. • Providers should use the contacts below for members enrolled in a Foreign Service Benefit Plan, MHBPor Rural Carrier Benefit Plan: − For precertification of pharmacy-covered specialty drugs — Foreign Service Benefit Plan, call Express Scripts at 1-800-922-8279. For MHBP and Rural Carrier Benefit Plan, call CVS Caremark® at 1-800-237-2767. − For precertification of all other listed drugs — Foreign Service Benefit Plan, call 1-800-593-2354. For MHBP, call 1-800-410-7778. For Rural Carrier Benefit Plan, call 1-800-638-8432.

Abraxane (paclitaxel) – precertification required for Calcitonin -Related Peptide (CGRP) receptor Medicare Advantage members only inhibitors Acthar Gel/H. P. Acthar (corticotropin) Vyepti (eptinezumab-jjmr) — precertification for the Adakveo (crizanlizumab-tmca) – precertification for drug and site of care required the drug and site of care required Cardiovascular — PCSK9 inhibitors: Adcetris (brentuximab vedotin) Praluent* (alirocumab) Alpha 1-proteinase inhibitor (human) Repatha* (evolocumab) (precertification for the drug and site of care Chimeric Antigen Receptor T-Cell Therapy (CAR-T) required): — Contact National Medical Excellence at Aralast NP (alpha 1-proteinase inhibitor) 1-877-212-8811 Glassia (alpha 1-proteinase inhibitor) Abecma (idecabtagene vicleucel) — Prolastin-C (alpha 1-proteinase inhibitor) precertification required effective 6/1/2021 Zemaira (alpha 1- proteinase inhibitor) Breyanzi (lisocabtagene maraleucel) — Amyotrophic Lateral Sclerosis (ALS) drugs: precertification required effective 5/7/2021 Radicava (edaravone) — precertification for the Kymriah (tisagenlecleucel) drug and site of care required Tecartus (brexucabtagene autoleucel) Avastin (bevacizumab), 10 mg — precertification required for oncology indications only Yescarta (axicabtagene ciloleucel) Aveed (testosterone undecanoate) Cosela (trilaciclib) — precertification required effective 5/7/2021 Belrapzo (bendamustine HCl) Crysvita (burosumab) — precertification for the Bendeka (bendamustine HCl) drug and site of care required Benlysta (belimumab) - precertification for the Cyramza (ramucirumab) drug and site of care required Danyelza (naxitamab-gqgk) — precertification Besponsa (inotuzumab ozogamicin) required effective 3/1/2021 Blenrep (belantamab mafodotin-blmf) Darzalex (daratumumab) Botulinum toxins: Darzalex Faspro (daratumumab and hyaluronidase­ Botox (onabotulinumtoxinA) fihj) Dysport (abobotulinumtoxinA) Dupixent* (dupilumab) Myobloc (rimabotulinumtoxinB) Empliciti (elotuzumab) Xeomin (incobotulinumtoxinA) Cablivi (caplacizumab-yhdp)

Proprietary

Enzyme replacement drugs: Granulocyte-colony stimulating factors, cont. Aldurazyme (laronidase) — precertification Nivestym (filgrastim-aafi) for the drug and site of care required Nyvepria (pegfilgrastim-apgf) — precertification Brineura (cerliponase alfa) required effective 2/1/2021 Cerezyme (imiglucerase) — precertification for Udenyca (pegfilgrastim-cbvq) the drug and site of care required. Zarxio (filgrastim-sndz) Elaprase (idursulfase) — precertification Ziextenzo (pegfilgrastim-bmez) for the drug and site of care required Growth hormone: Elelyso (taliglucerase alfa) — precertification for the drug and site of Genotropin* (somatropin) care required Humatrope* (somatropin) Fabrazyme (agalsidase beta) — Increlex* (mecasermin) precertification for the drug and site of Norditropin*(somatropin) care required Nutropin AQ* (somatropin) Kanuma (sebelipase alfa) — precertification for the Omnitrope* (somatropin) drug and site of care required Saizen* (somatropin) Lumizyme (alglucosidase alfa) — precertification Serostim* (somatropin) for the drug and site of care required Sogroya* (somapacitan-beco) – precertification Mepsevii (vestronidase alfa-vjbk) — precertification required effective 2/11/2021 for the drug and site of care required Zomacton* (somatropin [rDNA origin]) Naglazyme (galsulfase) — precertification for Zorbtive* (somatropin) the drug and site of care required Hepatitis C drugs Strensiq (asfotase alfa) Daklinza* (daclatasvir) Vimizim (elosulfase alfa) — precertification for Epclusa (sofosbuvir velpatasvir) the drug and site of care required Harvoni (sofosbuvir/ledipasvir) VPRIV (velaglucerase alfa) — precertification for the drug and site of care required Mavyret (glecaprevir/pibrentasvir) Erbitux (cetuximab) Olysio* (simeprevir) Erythropoiesis-stimulating agents: Sovaldi* (sofosbuvir) Aranesp (darbepoetin alfa) Technivie* (ombitasvir/paritaprevir/ritonavir) Epogen (epoetin alfa) Viekira Pak* (paritaprevir/ritonavir/ombitasvir/dasabuvir) Mircera (epoetin beta) Viekira XR* (ombitasvir/paritaprevir/ritonavir and Procrit (epoetin alfa) dasabuvir) Retacrit (recombinant human erythropoietin) Vosevi* (sofosbuvir/ velpatasvir/ voxilaprevir) Evkeeza (evinacumab-dgnb) — precertification Zepatier* (elbasvir/grazoprevir) for the drug and site of care required effective Hereditary angioedema agents: 5/7/2021 Berinert (C1 esterase inhibitor) Evrysdi () Cinryze (C1 esterase inhibitor) – precertification for Feraheme (ferumoxytol) the drug and site of care required Fusilev (levoleucovorin) Firazyr (icatibant acetate) Gattex (teduglutide) Haegarda (C1 esterase inhibitor subcutaneous Givlaari (givosiran) – precertification for drug [human]) and site of care required Kalbitor (ecallantide) Granulocyte-colony stimulating factors: Ruconest (C1 esterase inhibitor) Fulphila (pegfilgrastim-jmdb) Takhzyro (lanadelumab) Granix (tbo-filgrastim) HER2 receptor drugs: Leukine (sargramostim) Enhertu (fam-trastuzumab deruxtecan-nxki) Neulasta (pegfilgrastim) Herceptin (trastuzumab) Neupogen (filgrastim)

HER2 receptor drugs, cont. Immunologic agents, cont. Herceptin Hylecta (trastuzumab and Ilumya* (tildrakizumab) hyaluronidase-oysk) Inflectra (infliximab-dyyb) — precertification for the Herzuma (trastuzumab-pkrb) drug and site of care required Kadcyla (ado-trastuzumab emtansine) Kevzara* (sarilumab) Kanjinti (trastuzumab-anns) Kineret* (anakinra) Margenza (margetuximab-cmkb) – Olumiant* (baricitinib) Orencia precertification required effective 4/1/2021 SQ* (abatacept) Ogivri (trastuzumab-dkst) Orencia IV (abatacept) — precertification for Ontruzant (trastuzumab-dttb) the drug and site of care required Perjeta (pertuzumab) Otezla* (apremilast) Phesgo (pertuzumab/trastuzumab/hyaluronidase­ Remicade (infliximab) — precertification for zzxf) the drug and site of care required Trazimera (trastuzumab-qyyp) Renflexis (infliximab-abda) — precertification for the Ilaris* (canakinumab) drug and site of care required Imlygic (talimogene laherparepvec) Riabni (rituximab-arrx) — precertification required effective 4/2/2021 Immunoglobulins (precertification for the drug and site of care required): Rinvoq (upadacitinib) Asceniv (immune globulin) Rituxan (rituximab) Bivigam (immune globulin) Rituxan Hycela (rituximab/hyaluronidase human) Carimune NF (immune globulin) Ruxience (rituximab-pvvr) Cutaquig (immune globulin) Siliq* (brodalumab) Cuvitru (immune globulin SC [human]) Simponi* (golimumab) Flebogamma (immune globulin) Simponi Aria (golimumab) — precertification for GamaSTAN S/D (immune globulin) the drug and site of care required Gammagard, Gammagard S/D (immune globulin) Skyrizi* (risankizumab-rzaa) Gammaked (immune globulin) Stelara* (ustekinumab) Gammaplex (immune globulin) Stelara IV (ustekinumab) Gamunex-C (immune globulin) Taltz* (ixekizumab) Hizentra (immune globulin) Tremfya* (guselkumab) HyQvia (immune globulin) Truxima (rituximab-abbs) Octagam (immune globulin) Xeljanz*, Xeljanz XR* (tofacitinib) Panzyga (immune globulin) Injectable infertility drugs: Privigen (immune globulin) chorionic gonadotropin Xembify (immune globulin) Bravelle (urofollitropin) Immunologic agents: Cetrotide (cetrorelix acetate) Avsola (infliximab-axxq) — precertification Follistim AQ (follitropin beta) for the drug and site of care required Ganirelix AC (ganirelix acetate) Actemra (tocilizumab) — precertification for Gonal-f (follitropin alfa) the drug and site of care required Gonal-f RFF (follitropin alfa) Actemra* SC (tocilizumab) Menopur (menotropins) Cimzia* (certolizumab pegol) Novarel (chorionic gonadotropin) Cosentyx* (secukinumab) Ovidrel (choriogonadotropin alfa)

Enbrel* (etanercept) Pregnyl (chorionic gonadotropin) Enspryng* (satralizumab) Injectafer (ferric carboxymaltose injection) Entyvio (vedolizumab) — precertification for the Jelmyto (mitomycin) drug and site of care required Khapzory (levoleucovorin) Humira* (adalimumab) Lartruvo (olaratumab)

Luteinizing hormone-releasing hormone Natpara (parathyroid hormone) (LHRH) agents: Nulibry (fosdenopterin) — precertification required Eligard (leuprolide acetate) effective 6/1/2021 Firmagon (degarelix) Onpattro (patisiran) — precertification for the Lupron Depot (leuprolide acetate), 7.5 mg drug and site of care required Trelstar (triptorelin pamoate) Ophthalmic injectables: Zoladex (goserelin) Beovu (brolucizumab-dbll) Lumoxiti (moxetumomab pasudotox-tdfk) Eylea (aflibercept) Makena (hydroxyprogesterone caproate) Lucentis (ranibizumab) Monjuvi (tafasitamab-cxix) Luxturna (voretigene neparvovec-rzyl) — precertification for the drug and site of care Multiple sclerosis drugs: required Aubagio* (teriflunomide) Macugen (pegaptanib) Avonex* (interferon beta-1a) Tepezza (teprotumumab-trbw) – precertification Bafiertam* (monomethyl fumarate) for the drug and site of care required Betaseron* (interferon beta-1b) Osteoporosis drugs: Copaxone* (glatiramer acetate) Bonsity* (teriparatide) Extavia* (interferon beta-1b) Evenity* (romosozumab-aqqg) Gilenya* (fingolimod hydrochloride) Forteo* (teriparatide) Glatopa* (glatiramer acetate injection) Miacalcin (calcitonin) Kesimpta* (ofatumumab) Prolia (denosumab) Lemtrada (alemtuzumab), — precertification Tymlos* (abaloparatide) for the drug and site of care required Oxlumo (lumasiran) — precertification for the drug Mavenclad* (cladribine) and site of care required effective 3/17/2021 Mayzent* (siponimod) Padcev (enfortumab vedotin) Ocrevus (ocrelizumab) — precertification for Parsabiv (etelcalcetide) the drug and site of care required PD1/PDL1 drugs (precertification for the drug Plegridy* (peginterferon beta-1a) and site of care required): Ponvory* (ponesimod) — precertification Bavencio (avelumab) required effective 5/1/2021 Imfinzi (durvalumab) Rebif* (interferon beta-1a) Keytruda (pembrolizumab) Tecfidera* (dimethyl fumarate) Libtayo (cemiplimab-rwlc) Tysabri (natalizumab) — precertification for the drug and site of care required Opdivo (nivolumab) Vumerity* (diroximel fumarate) Tecentriq (atezolizumab) Zeposia* (ozanimod) Pepaxto (melphalan flufenamide) — precertification required effective 6/1/2021 Muscular dystrophy drugs: Polivy (polatuzumab vedotin-piiq) Amondys 45 () — precertification for the drug and site of care required Provenge (sipuleucel-T) effective 6/1/2021 Pulmonary arterial hypertension drugs: Exondys 51 () — precertification All epoprostenol sodium and sildenafil citrate* for the drug and site of care required Adcirca* (Alyq, tadalafil) Emflaza* (deflazacort) Adempas* (riociguat) Viltepso () — precertification for Flolan (epoprostenol sodium) the drug and site of care required Letairis* (ambrisentan) Vyondys 53 () — precertification Opsumit* (macitentan) for the drug and site of care required Orenitram* (treprostinil diolamine) Mvasi (bevacizumab-awwb) Remodulin (treprostinil sodium) Myalept (metreleptin) Revatio* (sildenafil citrate)

Pulmonary arterial hypertension drugs, cont. Tegsedi (inotersen) Tracleer* (bosentan) Treanda (bendamustine HCl) Tyvaso (treprostinil) Trodelvy (sacituzumab govitecan-hziy) Uptravi* (selexipag) Ultomiris (Ravulizumab-cwvz) — Veletri (epoprostenol sodium) precertification for the drug and site of care Ventavis (iloprost) required Reblozyl (luspatercept) Uplizna (inebilizumab-cdon) — Respiratory injectables (precertification precertification for the drug and site of care required and site of care required): required Cinqair (reslizumab) Vectibix (panitumumab) Fasenra (benralizumab) Viscosupplementation: Nucala (mepolizumab) Durolane () Xolair (omalizumab) Euflexxa, Hyalgan, Genvisc, Supartz FX, TriVisc, Visco 3 (sodium hyaluronate) Sarclisa (isatuximab-irfc) Gel-One (cross-linked hyaluronate) Soliris (eculizumab) — precertification for the drug and site of care required Gelsyn­3, Hymovis (hyaluronic acid) Somatostatin agents: Monovisc, Orthovisc (sodium hyaluronate) Bynfezia (octreotide) Synojoynt, Triluron (1% sodium hyaluronate) Sandostatin (octreotide) Synvisc, Synvisc-One (hylan) Sandostatin LAR (octreotide acetate) Xgeva (denosumab) Signifor (pasireotide) Xofigo (radium Ra 223 dichloride) Signifor LAR (pasireotide) Yervoy (ipilimumab) — precertification for the drug Somatuline (lanreotide) and site of care required Somavert (pegvisomant) Zirabev (bevacizumab-bvzr) Spinraza () Zolgensma (-xioi) – precertification for the drug and site of care Spravato (esketamine) required Synagis (palivizumab) Zulresso (brexanolone)

Special programs, continued

BRCA genetic testing — 1-877-794-8720 Cataracts, cont. See #9 in the General information section for For all Medicare only (MEHMO and MEPOS) more guidance. cataract surgery related requests, providers should Through our expanded national provider network: contact iCare Health Solutions to request preauthorization. You can reach iCare at • Quest — 1-866-436-3463 1-855-373-7627. • Ambry — 1-866-262-7943

• Baylor Miraca Genetics Laboratories, LLC— 1-800-411- GENE (1-800-411-4363) Diagnostic Cardiology (cardiac rhythm implantable • BioReference, GeneDX, Genpath— devices, cardiac catheterization) 1-888-729-1206 See #9 and #10 in the General information • Invitae — 1-800-436-3037 section for more guidance. • LabCorp — 1-855-488-8750 Precertification for all members with plans • Medical Diagnostic Laboratories—1-877-269-0090 applicable to this precertification list • Myriad Genetics —1-800-469-7423 unless services are emergent: • Progenity — 1-855-293-2639 • Providers in all states where applicable, Providers can use the BRCA form located online except New York and northern New under the “Medical Precertification” section to Jersey, should contact MedSolutions DBA submit precertification requests. eviCore healthcare to request

preauthorization. You can reach Find genetic counselors online MedSolutions DBA eviCore healthcare: For a list of our contracted providers, including our - Online at evicore.com telephonic provider (Informed DNA), visit our - By phone at 1-888-693-3211 between7 AM provider directory. and 8 PM ET - By fax at 1-844-822-3862, Monday Chiropractic precertification through Friday during normal See #9 in the General information section for business hours, or as required additional guidance. by federal or state regulations Chiropractic precertification required only in the • Providers in New York and northern states listed HMO-based plan members only New Jersey should contact CareCore AZ through American Specialty Health National DBA eviCore healthcare to (ASH)1-800-972-4226 request preauthorization. You can reach HMO-based plan and group Medicare members only CareCore National DBA eviCore CA through American Specialty Health healthcare: (ASH)1-800-972-4226 - Online at evicore.com For all members (with commercial and Aetna Medicare - By phone at 1-888-622-7329 for New York or 1-888-647-5940 for northern New Jersey Advantage plans applicable to this precertification list):

GA through American Specialty Health Hip and knee arthroplasties (ASH) 1-800-972-4226 See #9 and #10 in the General information For all members (with certain commercial plans, and section for more guidance. Aetna Medicare Advantage plans, applicable to this Precertification for all members with precertification list): plans applicable to this precertification DE, NJ, NY, PA, WV: through list unless services are emergent: National Imaging Associates • Providers in all states where applicable, 1-866-842-1542 except New York and northern New Jersey, should contact MedSolutions DBA Cataract surgery eviCore healthcare to request For all Georgia Medicare only (MEHMO and preauthorization on. You can reach MEPPO) cataract surgery related requests, MedSolutions DBA eviCore healthcare: providers should contact iCare Health Solutions to - Online at evicore.com request preauthorization. You can reach iCare at - By phone at 1-888-693-3211 1-844-210-7444. between 7 AM and 8 PM ET

Special programs, continued

Hip and knee arthroplasties, cont. Outpatient physical therapy (PT) and occupational By fax at 1-844-822-3862, Monday therapy (OT) precertification through Friday during normal See #9 and #10 in the General information section for business hours, or as required by federal or state regulations additional guidance. - Providers in New York and northern New Through OrthoNet 1-800-771-3205 Jersey should contact CareCore National DBA • CT— for all members with plans applicable eviCore healthcare to request preauthorization. to this precertification list You can reach CareCore National DBA eviCore Through Optum Health 1-800-344-4584 (Only healthcare: Optum Health/Aetna-contracted providers - Online at evicore.com should call this number for questions and service - By phone at 1-888-622-7329 for New York requests.) or • DC, GA, NC, SC, VA — For all members - 1-888-647-5940 for northern New Jersey with plans applicable to this precertification list Home health care • Program also applies to members in Chicago, northern All Texas Medicare only (MEHMO and MEPPO) home IL and northwest IN (Lake and Porter counties) health-related requests for in-home skilled nursing, • Through National Imaging Associates physical therapy, occupational therapy, speech therapy, a 1-866-842- 1542 home health aide and medical social work will require • DE, NJ, NY, PA, WV for members with precertification through myNEXUS. Providers in Texas should contact myNEXUS to request certain commercial plans, and Aetna precertification Medicare Advantage plans, applicable to • Go to Portal.myNEXUScare.com/Account/Login this precertification list (registration is required). • Fax the form to 1-866-996-0077 management • Questions? Call myNEXUS Intake at See #9 and #10 in the General information section for • 1-833-585-6262 from 8 AM to 8 PM ET, Monday additional guidance. through Friday or Precertification for all members with plans applicable to • Go to http://www.mynexuscare.com/aetna for this precertification list unless services are emergent. more details • Providers in all states where applicable, except

Infertility program — 1-800-575-5999 New York and northern New Jersey, should See #9 in the General information section for contact MedSolutions DBA eviCore healthcare additional guidance. to request preauthorization on. You can reach MedSolutions DBA eviCore healthcare: - Online at evicore.com Mental health or substance abuse services - By phone at 1-888-693-3211between 7 AM and 8 precertification—See the member’s ID card See PM ET #9 in the General information section for additional - By fax at 1-844 -822-3862, Monday through guidance. Friday, during normal business hours,

or as required by federal or state National Medical Excellence Program regulations By phone at 1-877-212-8811 for the following: • Providers in New York and northern New • Kymriah (tisagenlecleucel), Tecartus Jersey should contact CareCore National (brexucabtagene autoleucel) and Yescarta DBA eviCore healthcare to request (axicabtagene ciloleucel) preauthorization. You can reach CareCore • All major organ transplant evaluations and National DBA eviCore healthcare: transplants including, but not limited to, , - Online at evicore.com liver, heart, lung and pancreas, and bone - By phone at 1-888-622-7329 for New York or marrow replacement or stem cell transfer after 1-888-647-5940 for northern New Jersey high-dose chemotherapy

Special programs, continued

Polysomnography (attended sleep studies) Radiology imaging, cont. See #9 and #10 in the General information section for You can reach MedSolutions DBA eviCore more guidance. healthcare: - Online at evicore.com Precertification for all members with plans - By phone at 1-888-693-3211 between7 AM and 8 applicable to this precertification list when PM ET performed in any - By fax at 1-844-822-3862, Monday facility except inpatient, through Friday during normal business emergency room and observation hours or as required by federal or state bed status regulations • Providers in all states where applicable, • Providers in New York and northern New except New York and northern New Jersey should contact CareCore National DBA Jersey, should contact MedSolutions eviCore healthcare to request preauthorization. DBA eviCore healthcare to request You can reach CareCore National DBA preauthorization. You can reach eviCore healthcare: MedSolutions DBA eviCore healthcare: - Online at evicore.com - Online at evicore.com - By phone at1-888-622-7329 New York or - By phone at 1-888-693-3211 between 1-888-647-5940 for northern New Jersey 7 AM and 8 PM ET

- By fax at 1- 844 -822-3862, Monday through Radiation oncology Friday • Complex during normal business hours, or as required by federal or state regulations • 3D Conformal • Providers in New York and northern New Jersey • Stereotactic Radiosurgery (SRS) should contact CareCore National DBA eviCore • Stereotactic Body healthcare to request preauthorization. You can Radiation Therapy (SBRT) reach CareCore National DBA eviCore • Image Guided Radiation Therapy healthcare: (IGRT) - Online at evicore.com • Intensity-Modulated Radiation - By phone at 1-888-622-7329 for New York or Therapy (IMRT) 1-888-647-5940 for northern New Jersey • Proton Beam Therapy • Neutron Beam Therapy Pre-implantation genetic testing — • Brachytherapy 1-800-575-5999 • Hyperthermia See #9 in the General information section for • Radiopharmaceuticals more guidance. See #9 and #10 in the General informationsection Radiology imaging for additional guidance.

See #9 and #10 in the General information Precertification for all members with HMO-based, section for more guidance. Precertification for Aetna Medicare Advantage plans, and insured Aetna all members with plans applicable to this commercial when performed in any facility except precertification list when performed in any inpatient, emergency room and observation bed facility except inpatient, emergency room and status. observation bed status. • Providers should contact CareCore • Providers in all states where applicable, National DBA eviCore healthcare to except New York and northern New Jersey, request preauthorization. You can should contact MedSolutions DBA eviCore reach CareCore National DBA healthcare to request preauthorization. eviCore healthcare: - Online at evicore.com By phone at 1-888-622-7329

General information 1. We collect information before elective inpatient • For precertification in Texas, we use the utilization admissions and/or selected ambulatory review process to determine whether the requested procedures and services at the time of service, procedure, or medical device precertification. meets the company’s clinical criteria for coverage. • We’ll review precertification requests using Precertification doesn’t mean payment for care or one of the following processes if the services to fully insured HMO and PPO members as member’s plan covers the services: defined by Texas law. − Notification is a data-entry process. It • If member eligibility and plan coverage doesn’t require judgment or interpretation for the procedure/ service you asked for for benefits coverage. hasn’t changed, precertification approvals − Medical review – Coverage are valid for six months in all states. This determinations made for items on the is the case unless we tell you otherwise precert list are utilization review when you receive the precertification decisions. We review plan document s decision. and (when applicable) clinical • Every year, in January and July, we information. This is how we determine typically update the precertification list. But whether the requested service, we m ay add new FDA-approved drugs to the procedure, prescription drug or medical list at different times. device meets the clinical guidelines/criteria • Visit Clinical Policy Bulletins and our for coverage. online provider directory. • We need to receive requests for • The precertification process doesn’t include precertification before you provide services. verbal or written requests for information − We encourage providers to submit about benefits or services not on the precertification requests at least two precertification lists. Our staff members are weeks before the scheduled educated to determine whether a caller is services. making an inquiry or requesting a coverage − To save you time, it’s best to submit decision/organization determination as part precertification requests and inquiries of the intake process. electronically. This is the quickest way to • Find more about notification and coverage receive an authorization for services determinations. requiring precertification. If you need help, 2. We don’t offer all plans in all service areas, and not just call us. Look for the “precertification” all plans include all services listed. For example, number on the member’s ID card. precertification programs don’t apply to fully insured − If you don’t precertify the services on this members in Indiana. list, the member’s health plan (the “health 3. Innovation Health Insurance Company and Innovation plan”), employer group or member won’t Health Plan, Inc. (Innovation Health) are affiliates of be financially responsible for the Aetna Life Insurance Company (Aetna) and its affiliates. applicable service(s) if you provide those Aetna and its affiliates provide certain management services. services for Innovation Health. • This material is for your information only. It’s 4. Find more information about notification and not meant to direct treatment decisions. coverage determinations. • The review of items on this list may vary at our discretion. If you receive approval for a 5. We require precertification when Aetna or Innovation particular service or supply, it’s for that service Health is the secondary payer. or supply only. • Services that don’t require precertification are subject to the coverage terms of the member’s plan.

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General information, continued 6. We require precertification for maternity and − Drug coverage continues for these newborn stays that are more than thestandard Connecticut members as long as the drug length of stay (LOS). Standard LOS for: is medically necessary and more medically • Vaginal deliveries is threedays or fewer beneficial than other covered drugs • Cesarean section is five daysor fewer • The prescribing provider must respond to requests for 7. Contact Aetna Pharmacy Management for more information. For fully insured members with a precertification of oral not on this Colorado state contract, we’ll approve or deny list. precertification requests within time frames mandated by • See #9 in General information section for Colorado Regulation 4-2-49 RX Prior Authorization. additional guidance.

• Their number is 1-800-414-2386. 9. For members enrolled in Foreign Service Benefit Plan, MHBP or Rural Carrier Benefit Plan: Precertification is • Call 1-866-782-2779 for information not required for cardiac catheterization, cardiac imaging, on injectable medications not listed. chiropractic services, transthoracic echocardiogram or 8. For drugs administered orally, by injection or physical/occupational therapy infusion: • Visit online provider directories: Foreign Service • Drugs newly approved by Benefit Plan; MHBP; Rural Carrier Benefit Plan

the FDA may require • Except as noted for drugs and medical injectables precertification review. and special programs, for all other services: • Fully insured Texas and Louisiana − Foreign Service Benefit Plan, call members continue to be covered for 1-800-593-2354 drugs added to the precertification list − MHBP, call 1-800-410-7778 according to their current plan design until their plan renewal date. − Rural Carrier Benefit Plan, call • Fully insured HMO members 1-800-638-8432 and fully insured Connecticut PPO 10. For members enrolled in Aetna Student Health members covered for drugs added to the or Allina Health|Aetna precertification is not required for the following outpatient services: precertification list continue to have coverage. • Diagnostic cardiology − Drug coverage continues for these • Hip and knee arthroplasties California members as long as the • Physical therapy and occupational therapy drug is appropriately prescribed • Pain management and considered safe and effective • Polysomnography treatment for the medical • Radiology imaging condition. • Radiation oncology

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates(Aetna). Aetna provides certain management services on behalf of its affiliates. Banner|Aetna, Texas Health Aetna, Allina Health|Aetna and Sutter Health|Aetna are affiliates of Aetna Life Insurance Company and its affiliates (Aetna). Aetna provides certain management services to these entities.

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