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Pre-Certification Requirements for Procedures, Programs & Drugs

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Pre-Certification Requirements for Procedures, Programs & Drugs Procedures, programs and drugs 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 therapy • 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 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, 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 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 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
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