Procedures, programs and that require precertification

Participating provider precertification list

Starting August 1, 2020

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 I (8/20)

Proprietary

For additional information, read all general precertification information 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 stays in a skilled nursing facility or rehabilitation by a participating provider facility, and maternity and newborn stays that 19. Orthognathic surgery procedures, bone grafts, osteotomies and surgical exceed the standard length of stay (LOS) (See #5 management of the temporomandibular in the General Information section). joint 2. Ambulance 20. Osseointegrated implant Precertification required for transportation by 21. Osteochondral allograft/knee fixed- wing aircraft (plane) 22. Private duty nursing 3. Autologous chondrocyte implantation 23. Proton beam radiotherapy 4. Chiari malformation decompression surgery Also see Special Programs; Radiation Oncology 5. Cochlear device and/or implantation 24. Reconstructive or other 6. Coverage at an in-network benefit level procedures that maybe for out-of-network provider or facility considered cosmetic, such as: unless services are emergent. • Blepharoplasty/canthoplasty Some plans have limited or no out-of­network • Breast reconstruction/breast enlargement benefits. • Breast reduction/mammoplasty 7. Dental implants • Excision of excessive skin due to weight loss 8. Dialysis visits • Gastroplasty/gastric bypass When a participating provider initiates a • Lipectomy or excess fat removal request and dialysis is to be performed at a • Surgery for varicose veins, except stab phlebectomy nonparticipating facility, call 1-866-752-7021 25. Shoulder Arthroplasty including revision for precertification. Or fax applicable request procedures — precertification required for revision forms to 1-888-267-3277. procedures effective 7/1/2020 26. Spinal procedures, such as: 9. Dorsal column (lumbar) • Artificial intervertebral disc surgery (cervical spine) neurostimulators: trial or implantation • Arthrodesis for spine deformity — precertification 10. Electric or motorized wheelchairs and required effective 7/1/2020 scooters • Cervical laminoplasty 11. Endoscopic nasal balloon dilation procedures 12. Functional endoscopic sinus surgery (FESS) — • Cervical, lumbar and thoracic laminectomy precertification required effective 7/1/2020 and\or laminotomy procedures 13. Gender reassignment surgery • Kyphectomy — precertification required effective 14. Hip surgery to repair impingement syndrome 7/1/2020 15. Hyperbaric oxygen • Laminectomy with rhizotomy 16. Infertility services and pre-implantation • Spinal fusion surgery genetic testing 27. Uvulopalatopharyngoplasty, 17. Lower limb prosthetics, such as including laser- assisted procedures microprocessor-controlled lower limb 28. Ventricular assist devices prosthetics 29. Video electroencephalograph (EEG) 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, please call Express Scripts at 1-800-922-8279 − For MHBP and the Rural Carrier Benefit Plan, please 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], Koate, Koate-DVI (antihemophilic factor [human]) single chain) Alphanate (antihemophilic factor/von Willebrand Kogenate FS (antihemophilic factor [recombinant]) factor complex [human]) Kovaltry (antihemophilic factor [recombinant]) AlphaNine SD (coagulation factor IX [human]) Monoclate-P (antihemophilic factor [human]) Alprolix (coagulation factor IX [recombinant], Fc Mononine (coagulation factor IX [human]) fusion protein) NovoEight (turoctocog alfa) Bebulin (factor IX complex) NovoSeven RT (coagulation factor VIIa [recombinant]) BeneFix (coagulation factor IX [recombinant]) Nuwiq (simoctocog alfa) Coagadex (coagulation factor X [human]) Obizur (antihemophilic factor [recombinant], Corifact (factor XIII concentrate [human]) porcine sequence) Eloctate (antihemophilic factor [recombinant], Fc Profilnine (factor IX complex) fusion protein) Rebinyn (coagulation factor IX [recombinant], Esperoct [antihemophilic factor (recombinant), glycoPEGylated) glycopegylated-exei] — precertification Recombinate (antihemophilic factor [recombinant]) required effective 4/1/2020 RiaSTAP (fibrinogen concentrate [human]) FEIBA, FEIBA NF (anti-inhibitor coagulant complex) Rixubis (coagulation factor IX [recombinant]) Fibryga (fibrinogen, human) Sevenfact (coagulation factor VIIa [recombinant]­ Helixate FS (antihemophilic factor [recombinant]) jncw) — precertification required effective Hemlibra (emicizumab-kxwh) 7/9/2020 Tretten (coagulation factor XIII a-subunit Hemofil M (antihemophilic factor [human]) [recombinant]) Humate-P (antihemophilic factor/von Willebrand Vonvendi (von Willebrand factor [recombinant]) factor complex [human]) Wilate (von Willebrand factor/coagulation factor Idelvion (antihemophilic factor [recombinant]) VIII complex [human]) 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 (noted with *) 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 moreinformationabout preferred products or to find a precertification fax form. • Providers should use the contacts below for members enrolled in a Foreign Service Benefit Plan, MHBP or RuralCarrierBenefitPlan: − 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 effective 5/28/2020 the drug and site of care required effective Cardiovascular — PCSK9 inhibitors: 2/13/2020 Praluent* (alirocumab) Adcetris (brentuximab vedotin) Repatha* (evolocumab) Alpha 1-proteinase inhibitor (human) Chimeric Antigen Receptor T-Cell Therapy (CAR-T) (precertification for the drug and site of care — Contact National Medical Excellence at required): 1-877-212-8811 Aralast NP (alpha 1-proteinase inhibitor) Kymriah (tisagenlecleucel) Glassia (alpha 1-proteinase inhibitor) Yescarta (axicabtagene ciloleucel) Prolastin-C (alpha 1-proteinase inhibitor) Crysvita (burosumab) — precertification for Zemaira (alpha 1- proteinase inhibitor) the drug and site of care required Amyotrophic Lateral Sclerosis (ALS) drugs: Cyramza (ramucirumab) Radicava (edaravone) — precertification for the Darzalex (daratumumab) drug and site of care required Darzalex Faspro (daratumumab and Avastin (bevacizumab) — precertification required hyaluronidase-fihj) — precertification required effective 7/1/2020 effective 8/6/2020 Aveed (testosterone undecanoate) Dupixent* (dupilumab) Belrapzo (bendamustine HCl) — precertification Empliciti (elotuzumab) required effective 7/1/2020 replacement drugs: Bendeka (bendamustine HCl) — precertification Aldurazyme (laronidase) — precertification for the required effective 7/1/2020 drug and site of care required Benlysta (belimumab) - precertification for the Brineura (cerliponase alfa) drug and site of care required Cerezyme (imiglucerase) — precertification for the Besponsa (inotuzumab ozogamicin) drug and site of care required. Botulinum toxins: Elaprase (idursulfase) — precertification for Botox (onabotulinumtoxinA) the drug and site of care required Dysport (abobotulinumtoxinA) Elelyso (taliglucerase alfa) — precertification Myobloc (rimabotulinumtoxinB) for the drug and site of care required Xeomin (incobotulinumtoxinA) Fabrazyme (agalsidase beta) — Cablivi (caplacizumab-yhdp) precertification for the drug and site of care required Proprietary

Enzyme replacement drugs, cont. Hepatitis C drugs, cont. Kanuma (sebelipase alfa) — precertification for the Olysio* (simeprevir) drug and site of care required Sovaldi* (sofosbuvir) Lumizyme (alglucosidase alfa) — precertification Technivie* (ombitasvir/paritaprevir/ritonavir) for the drug and site of care required Viekira Pak* Mepsevii (vestronidase alfa-vjbk) — precertification (paritaprevir/ritonavir/ombitasvir/dasabuvir) for the drug and site of care required Viekira XR* (ombitasvir/paritaprevir/ritonavir and Naglazyme (galsulfase) — precertification for dasabuvir) the drug and site of care required Vosevi* (sofosbuvir/ velpatasvir/ voxilaprevir) Strensiq (asfotase alfa) Zepatier* (elbasvir/grazoprevir) Vimizim (elosulfase alfa) — precertification for Hereditary angioedema agents: the drug and site of care required Berinert (C1 esterase inhibitor) VPRIV (velaglucerase alfa) — precertification Cinryze (C1 esterase inhibitor) – precertification for the drug and site of care required for the drug and site of care required Erbitux () Firazyr (icatibant acetate) Erythropoiesis-stimulating agents: Haegarda (C1 esterase inhibitor subcutaneous Aranesp (darbepoetin alfa) [human]) Epogen (epoetin alfa) Kalbitor (ecallantide) Mircera (epoetin beta) Ruconest (C1 esterase inhibitor) Procrit (epoetin alfa) Takhzyro (lanadelumab) Retacrit (recombinant human erythropoietin) HER2 receptor drugs: Feraheme (ferumoxytol) — precertification Enhertu (fam-trastuzumab deruxtecan-nxki) — required effective 7/1/2020 precertification required effective 3/24/2020 Fusilev (levoleucovorin) Herceptin (trastuzumab) Gattex (teduglutide) Herceptin Hylecta (trastuzumab and Givlaari (givosiran) – precertification for drug hyaluronidase-oysk) and site of care required effective 2/13/2020 Herzuma (trastuzumab-pkrb) — precertification Granulocyte-colony stimulating factors: required effective 8/11/2020 Fulphila (pegfilgrastim-jmdb) Kadcyla (ado-trastuzumab emtansine) Granix (tbo-filgrastim) Kanjinti (trastuzumab-anns) Leukine (sargramostim) Ogivri (trastuzumab-dkst) — precertification Neulasta (pegfilgrastim) required effective 4/1/2020 Ontruzant (trastuzumab-dttb) — precertification Neupogen (filgrastim) required effective 8/11/2020 Nivestym (filgrastim-aafi) Perjeta (pertuzumab) Udenyca (pegfilgrastim-cbvq) Trazimera (trastuzumab-qyyp) — precertification Zarxio (filgrastim-sndz) required effective 4/1/2020 Ziextenzo (pegfilgrastim-bmez) – precertification Ilaris* (canakinumab) required effective 2/1/2020 Imlygic (talimogene laherparepvec) : Immunoglobulins (precertification for the drug and Genotropin* (somatropin) site of care required): Humatrope* (somatropin) Asceniv (immune globulin) — precertification Increlex* (mecasermin) required effective 3/1/2020 Norditropin*(somatropin) Bivigam (immune globulin) Nutropin AQ* (somatropin) Carimune NF (immune globulin) Omnitrope* (somatropin) Cutaquig (immune globulin) * (somatropin) Cuvitru (immune globulin SC [human]) Serostim* (somatropin) Flebogamma (immune globulin) Zomacton* (somatropin [rDNA origin]) GamaSTAN S/D (immune globulin) Zorbtive* (somatropin) Gammagard, Gammagard S/D (immune globulin) Hepatitis C drugs Gammaked (immune globulin) Daklinza* (daclatasvir) Gammaplex (immune globulin) Epclusa (sofosbuvir velpatasvir) Gamunex-C (immune globulin) Harvoni (sofosbuvir/ledipasvir) Hizentra (immune globulin) Mavyret (glecaprevir/pibrentasvir) HyQvia (immune globulin) Proprietary

Immunoglobulins, cont. Injectable infertility drugs, cont: Octagam (immune globulin) Gonal-f RFF (follitropin alfa) Panzyga (immune globulin) Menopur (menotropins) Privigen (immune globulin) Novarel (chorionic gonadotropin) Xembify (immune globulin) Ovidrel (choriogonadotropin alfa) Immunologic agents: Pregnyl (chorionic gonadotropin) Avsola (infliximab-axxq) — precertification Injectafer (ferric carboxymaltose injection) — for the drug and site of care required precertification required effective 7/1/2020 effective 8/1/2020 Jelmyto (mitomycin) — precertification required Actemra (tocilizumab) — precertification for effective 8/7/2020 the drug and site of care required Khapzory (levoleucovorin) Actemra* SC (tocilizumab) Lartruvo (olaratumab) Cimzia* (certolizumab pegol) Lumoxiti (moxetumomab pasudotox-tdfk) Cosentyx* (secukinumab) Makena (hydroxyprogesterone caproate) Enbrel* (etanercept) Multiple sclerosis drugs: Entyvio (vedolizumab) — precertification for Aubagio* (teriflunomide) the drug and site of care required Avonex* (interferon beta-1a) Humira* (adalimumab) Betaseron* (interferon beta-1b) Ilumya* (tildrakizumab) Copaxone* (glatiramer acetate) Inflectra (infliximab-dyyb) — precertification for Extavia* (interferon beta-1b) the drug and site of care required Gilenya* (fingolimod hydrochloride) Kevzara* (sarilumab) Glatopa* (glatiramer acetate injection) Kineret* (anakinra) Lemtrada (alemtuzumab) — precertification for Olumiant* (baricitinib) the drug and site of care required Orencia SQ* (abatacept) Mavenclad* () Orencia IV (abatacept) — precertification Mayzent* (siponimod) for the drug and site of care required Ocrevus (ocrelizumab) — precertification for the Otezla* (apremilast) drug and site of care required Remicade (infliximab) — precertification Plegridy* (peginterferon beta-1a) for the drug and site of care required Rebif* (interferon beta-1a) Renflexis (infliximab-abda) — precertification Tecfidera* (dimethyl fumarate) for the drug and site of care required Tysabri (natalizumab) — precertification for the Rinvoq (upadacitinib) drug and site of care required Rituxan (rituximab) Vumerity* (diroximel fumarate) — Ruxience (rituximab-pvvr) — precertification required effective 4/1/2020 precertification required effective 4/1/2020 Siliq* (brodalumab) Zeposia* (ozanimod) — precertification required effective 7/9/2020 Simponi* (golimumab) Simponi Aria (golimumab) — precertification Muscular dystrophy drugs: Exondys 51 () — precertification for the for the drug and site of care required drug and site of care required Skyrizi* (risankizumab-rzaa) Emflaza* (deflazacort) Stelara* (ustekinumab) Vyondys 53 () — precertification for Stelara IV (ustekinumab) the drug and site of care required effective Taltz* (ixekizumab) 3/10/2020 Tremfya* (guselkumab) Mvasi (bevacizumab-awwb) — precertification Truxima (rituximab-abbs) required effective 7/1/2020 Xeljanz*, Xeljanz XR* (tofacitinib) Myalept (metreleptin) Injectable infertility drugs: Natpara (parathyroid hormone) chorionic gonadotropin Onpattro (patisiran) — precertification for the Bravelle (urofollitropin) drug and site of care required Cetrotide (cetrorelix acetate) Ophthalmic injectables: Follistim AQ (follitropin beta) Beovu (brolucizumab-dbll) Ganirelix AC (ganirelix acetate) Eylea (aflibercept) Gonal-f (follitropin alfa) Lucentis (ranibizumab) Proprietary

Ophthalmic injectables, cont. Sandostatin LAR (octreotide acetate) — Luxturna (voretigene neparvovec-rzyl) — precertification required effective 7/1/2020 precertification for the drug and site of Sarclisa (isatuximab-irfc) — precertification required care required effective 5/28/2020 Macugen (pegaptanib) Soliris (eculizumab) — precertification for the drug Tepezza (teprotumumab-trbw) – and site of care required precertification for the drug and site of Somatuline (lanreotide) — precertification care required effective 5/1/2020 required effective 7/1/2020 Osteoporosis drugs: Spinraza () Bonsity* (teriparatide) – precertification Spravato (esketamine) required effective 5/1/2020 Synagis (palivizumab) Evenity* (romosozumab-aqqg) Tegsedi (inotersen) Forteo* (teriparatide) Treanda (bendamustine HCl) — precertification Miacalcin (calcitonin) required effective 7/1/2020 Prolia (denosumab) Trodelvy (sacituzumab govitecan-hziy) — Tymlos* (abaloparatide) precertification required effective 7/9/2020 Padcev (enfortumab vedotin) — precertification Ultomiris (Ravulizumab-cwvz) — required effective 3/24/2020 precertification for the drug and site of care Parsabiv (etelcalcetide) required PD1/PDL1 drugs (precertification for the Vectibix (panitumumab) drug and effective 7/1/2020 site of care Viscosupplementation: required): Durolane () Bavencio () Euflexxa, Hyalgan, Genvisc, Supartz, TriVisc, Imfinzi (durvalumab) Visco 3 (sodium hyaluronate) Keytruda (pembrolizumab) Gel-One (cross-linked hyaluronate) Libtayo (cemiplimab-rwlc) Gelsyn­3, Hymovis (hyaluronic acid) Opdivo (nivolumab) Monovisc, Orthovisc (sodium hyaluronate) Tecentriq (atezolizumab) Synojoynt, Triluron (1% sodium hyaluronate) Polivy (polatuzumab vedotin-piiq) Synvisc, Synvisc-One (hylan) Provenge (sipuleucel-T) Xgeva (denosumab) Pulmonary arterial hypertension drugs: Xofigo (radium Ra 223 dichloride) All epoprostenol sodium and sildenafil citrate* Yervoy (ipilimumab) — precertification for the drug Adcirca* (Alyq, tadalafil) and effective 7/1/2020 site of care required Adempas* (riociguat) Zirabev (bevacizumab-bvzr) — precertification Flolan (epoprostenol sodium) required effective 7/1/2020 Letairis* (ambrisentan) Zoladex (goserelin) — precertification required Opsumit* (macitentan) effective 7/1/2020 Orenitram* (treprostinil diolamine) Zolgensma (-xioi) – Remodulin (treprostinil sodium) precertification for the drug and site of care Revatio* (sildenafil citrate) required Tracleer* (bosentan) Zulresso (brexanolone) — precertification Tyvaso (treprostinil) required effective 7/1/2020 Uptravi* (selexipag) Veletri (epoprostenol sodium) Ventavis (iloprost) Reblozyl (luspatercept) — precertification required effective 2/13/2020 Respiratory injectables: Cinqair (reslizumab) Fasenra (benralizumab) Nucala (mepolizumab) Xolair (omalizumab)

Proprietary

Special programs BRCA genetic testing — 1-877-794-8720 Diagnostic Cardiology (cardiac rhythm See #9 in the General information section for implantable devices, cardiac catheterization) additional guidance. See #9 and #10 in the General information section Through our expanded national provider network: for additional guidance. • Quest — 1-866-436-3463 Precertification for all members with plans • Ambry — 1-866-262-7943 applicable to this precertification list unless • Baylor Miraca Genetics Laboratories, LLC— services are emergent: 1-800-411- GENE • Providers in all states where applicable, except • BioReference, GeneDX, Genpath— New York and northern New Jersey, should 1-888-729-1206 contact MedSolutions DBA eviCore healthcare • Invitae — 1-800-436-3037 to request preauthorization. You can reach • LabCorp —1-855-488-8750 • Medical Diagnostic Laboratories—1-877-269-0090 MedSolutions DBA eviCore healthcare: • Myriad Genetics —1-800-469-7423 - Online at evicore.com • Progenity — 1-855-293-2639 - By phone at 1-888-693-3211between7 AM and 8 PM ET Providers can use the BRCA form located - By fax at 1-844-822-3862, Monday online under the “Medical Precertification” through Friday during normal section to submit precertification requests. Find genetic counselors online — for a list of our business hours, or as required by contracted providers, including our telephonic federal or state regulations provider (Informed DNA), visit our provider • Providers in New York and northern New directory. Jersey should contact CareCore National DBA Chiropractic precertification eviCore healthcare to request See #9 in the General information section for preauthorization. You can reach CareCore additional guidance. National DBA eviCore healthcare: Chiropractic precertification required only in - Online at evicore.com - By phone at 1-888-622-7329 for the states listed HMO-based plan members New York or 1-888-647-5940 only for northern New Jersey AZ through American Specialty Health Hip and knee arthroplasties (ASH)1-800-972-4226 See #9 and #10 in the General informationsection HMO-based plan and group Medicare members for additional guidance. only Precertification for all members with plans CA through American Specialty Health applicable to this precertification list unless (ASH)1-800-972-4226 services are emergent: For all members (with commercial and Aetna • Providers in all states where applicable, except Medicare Advantage plans applicable to this New York and northern New Jersey, should precertification list): contact MedSolutions DBA eviCore healthcare GA through American Specialty Health to request preauthorization on. You can reach (ASH) 1-800-972-4226 MedSolutions DBA eviCore healthcare: For all members (with certain commercial plans, - Online at evicore.com and Aetna Medicare Advantage plans, applicable - By phoneat 1-888-693-3211 between 7 to this precertification list): AM and 8PM ET DE, NJ, NY, PA, WV: through - By fax at 1-844-822-3862, Monday through Friday during normal business hours, National Imaging Associates or as required by federal or state 1-866-842-1542 regulations

Proprietary

Special programs, continued

Hip and knee arthroplasties, cont. Through Optum Health 1-800-344-4584 (only - Providers in New York and northern New Optum Health/Aetna-contracted providers Jersey should contact CareCore National DBA should call this number for questions and service eviCore healthcare to request requests) preauthorization. You can reach CareCore • DC, GA, NC, SC, VA — For all members National DBA eviCore healthcare: with plans applicable to this - Online at evicore.com precertification list - By phone at 1-888-622-7329 for New York • Program also applies to members in Chicago, northern or IL and northwest IN (Lake and Porter counties) - for northern New Jersey 1-888-647-5940 • Through National Imaging Associates 1-866- Home Health Care 842- 1542 Effective March 1, 2020, all Texas Medicare only (MEHMO • DE, NJ, NY, PA, WV for members with and MEPPO) home health-related requests for in-home certain commercial plans, and Aetna skilled nursing, physical therapy, occupational therapy, speech therapy, a home health aide and medical social Medicare Advantage plans, applicable to work will require precertification through myNEXUS. this precertification list Providers in Texas should contact myNEXUS to request management precertification See #9 and #10 in the General information section for • Go to Portal.myNEXUScare.com/Account/Login additional guidance. (registration is required). Precertification for all members with plans applicable to • Fax the form to 1-866-996-0077 this precertification list unless services are emergent. • Questions? Call myNEXUS Intake at 1-833­ • Providers in all states where applicable, except 585-6262 from 8 AM to 8 PM ET, Monday through New York and northern New Jersey, should Friday or contact MedSolutions DBA eviCore healthcare • Go to http://www.mynexuscare.com/aetna for to request preauthorization on. You can reach more details MedSolutions DBA eviCore healthcare: Infertility program — 1-800-575-5999 - Online at evicore.com See #9 in the General information section for - By phone at 1-888-693-3211between 7 AM and 8 additional guidance. PM ET Mental health or substance abuse services - By fax at 1-844 -822-3862, Monday through precertification—See the member’s ID card See Friday during normal business hours, #9 in the General information section for additional or as required by federal or state guidance. regulations National Medical Excellence Program • Providers in New York and northern New Jersey should contact CareCore National By phone at 1-877-212-8811 for the following: DBA eviCore healthcare to request • Kymriah (tisagenlecleucel) andYescarta preauthorization. You can reach CareCore (axicabtagene ciloleucel) National DBA eviCore healthcare: • All major organ transplant evaluations and - Online at evicore.com transplants including, but not limited to, - By phone at 1-888-622-7329 for New York or , liver, heart, lung and pancreas, and 1-888-647-5940 for northern New Jersey bone marrow replacement or stem cell transfer after high-dose chemotherapy Outpatient physical therapy (PT) and occupational therapy (OT) precertification See #9 and #10 in the General information section for additional guidance. Through OrthoNet 1-800-771-3205 • CT— for all members with plans applicable to this precertification list

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Special programs, continued

Polysomnography (attended sleep studies) - By fax at 1-844-822-3862, Monday See #9 and #10 in the General information section for through Friday during normal business additional guidance. hours or as required by federal or state Precertification for all members with plans regulations applicable to this precertification list when • Providers in New York and northern New performed in any Jersey should contact CareCore National DBA facility except inpatient, eviCore healthcare to request emergency room and preauthorization. You can reach CareCore observation bed status National DBA eviCore healthcare: • Providers in all states where applicable, - Online at evicore.com except New York and northern New - By phone at1-888-622-7329 New York or Jersey, should contact MedSolutions DBA 1-888-647-5940 for northern New Jersey eviCore healthcare to request Radiation oncology preauthorization. You can reach • Complex MedSolutions DBA eviCore healthcare: • 3D Conformal - Online at evicore.com • Stereotactic Radiosurgery (SRS) - By phone at 1-888-693-3211 between7 • StereotacticBodyRadiation AM and8 PM ET Therapy (SBRT) - By fax at 1- 844 -822-3862, Monday through • Image Guided Radiation Therapy Friday (IGRT) during normal business hours, or as • Intensity-Modulated Radiation required by federal or state regulations Therapy (IMRT) Polysomnography (attended sleep studies), cont. • Proton Beam Therapy • Providers in New York and northern New Jersey should contact CareCore National DBA eviCore • Neutron Beam Therapy healthcare to request preauthorization. You can • Brachytherapy reach CareCore National DBA eviCore • Hyperthermia healthcare: • Radiopharmaceuticals - Online at evicore.com See #9 and #10 in the General informationsection - By phone at 1-888-622-7329 for New York or for additional guidance. 1-888- 647-5940 for northern New Jersey Precertification for all members with HMO-based, Pre-implantation genetic testing — 1-800-575-5999 Aetna Medicare Advantage plans, and insured Aetna See #9 in the General information section for commercial when performed in any facility except additional guidance. inpatient, emergency room and observation bed Radiology imaging status. • Providers should contact CareCore See #9 and #10 in the General information National DBA eviCore healthcare to section for additional guidance. Precertification request preauthorization. You can for all members with plans applicable to this reach CareCore National DBA precertification list when performed in any eviCore healthcare: facility except inpatient, emergency room and - Online at evicore.com observation bed status. By phone at 1-888-622-7329 • Providers in all states where applicable, except New York and northern New Jersey, should contact MedSolutions DBA eviCore healthcare to request preauthorization. You can reach MedSolutions DBA eviCore healthcare: - Online at evicore.com - By phone at 1-888-693-3211between7 AM and 8 PM ET Proprietary

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

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General information, continued 6. We require precertification for maternity and b. Drug coverage continues for these newbornstays that are more thanthestandard 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 days or 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 • See #9 in General information section for by 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 1-866-782-2779for 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 physical/occupational therapy or 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 California 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 a. Drug coverage continues for these • Hip and knee arthroplasties California members as long as • Physical therapy and occupationaltherapy the drug is appropriately • Pain management prescribed and considered safe • Polysomnography and effective treatment for the • Radiology imaging medical 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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