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Aetna PA Info Procedures, programs and drugs 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 therapy • 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 drug 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 protein) 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 Medication 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 Gene-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)
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