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Procedures, Programs and Drugs You Must Precertify

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Procedures, Programs and Drugs You Must Precertify Procedures, programs and drugs you must precertify Participating provider precertification list Starting May 1, 2019 Applies to the following plans (also see General information section #1-#4 and #9): 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 HealthInsurance Company and/or Banner Health and Aetna Health Plan Inc. (Banner|Aetna),TexasHealth+Aetna HealthInsurance 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 X (5/19) 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). 16. Lower limb prosthetics, such as Services that require precertification: microprocessor-controlled lower limb 1. Inpatient confinements (except hospice) prosthetics For example, surgical and nonsurgical stays, stays in a 17. Nonparticipating freestanding ambulatory skilled nursing facility or rehabilitation facility, and surgical facility services, when referred by a maternity and newborn stays that exceed the standard participating provider length of stay (LOS) (See #5 in the General Information 18. Orthognathic surgery procedures, bone grafts, section). osteotomies and surgical management of the 2. Ambulance temporomandibular joint Precertification required for transportation by fixed- wing 19. Osseointegrated implant 20. Osteochondral allograft/knee aircraft (plane) 21. Private duty nursing 3. Autologous chondrocyte implantation 4. Chiari malformation decompression surgery 22. Proton beam radiotherapy 23. Reconstructive or other procedures that maybe 5. Cochlear device and/or implantation 6. Coverage at an in-network benefit level for considered cosmetic, such as: out-of-network provider or facility unless • Blepharoplasty/canthoplasty services are emergent. • Breast reconstruction/ breast enlargement • Breast reduction/mammoplasty Some plans have limited or no out-of­network benefits. • Excision of excessive skin due to weight loss 7. Dental implants • Gastroplasty/gastric bypass 8. Dialysis visits When a participating provider initiates request, and • Lipectomy or excess fat removal dialysis is to be performed at a nonparticipating facility, • Surgery for varicose veins, except stab phlebectomy 24. Shoulder Arthroplasty call 1-866-503-0857. Or fax applicable request forms to 25. Spinal procedures, such as: 1-888-267-3277. • Artificial intervertebral disc surgery (cervical spine) 9. Dorsal column (lumbar) neurostimulators: trial or • Cervical, lumbar and thoracic laminectomy and\or implantation laminotomy procedures 10. Electric or motorized wheelchairs and scooters • Laminectomy with rhizotomy 11. Endoscopic nasal balloon dilation procedures • Spinal fusion surgery 12. Gender reassignment surgery 26. Uvulopalatopharyngoplasty, including laser- 13. Hip surgery to repair impingement syndrome assisted procedures 14. Hyperbaric oxygen therapy 27. Ventricular assist devices 15. Infertility services and pre-implantation genetic 28. Video electroencephalograph(EEG) testing 29. Whole exome sequencing – precertification required effective 3/1/2019 Drugs and medical injectables Blood- clotting factors (precertification for outpatient infusion of this drug class is required) Call the precertification number listed on the member’s card, with the following exceptions. • Precertification of pharmacy-covered specialty drugs - For the Foreign Service BenefitPlan, please call Express Scripts at 1-800-922-8279 - For MHBP and the Rural Carrier Benefit Plan,please call CVS/Caremarkat 1-800-237-2767 Advate (antihemophilic factor, human recombinant ) Koate, Koate-DVI (antihemophilic factor [human]) Adynovate (antihemophilic factor [recombinant], PEGylated) Kogenate FS (antihemophilic factor [recombinant ]) Afstyla (antihemophilic factor [recombinant], single chain) Kovaltry (antihemophilic factor [recombinant]) Alphanate (antihemophilic factor/von Willebrand factor Monoclate-P (antihemophilic factor [human]) complex [human]) AlphaNine SD (coagulation factor IX Mononine (coagulation factor IX [human]) [human]) NovoEight (turoctocog alfa) Alprolix (coagulation factor IX [recombinant], Fc fusion protein) NovoSeven RT (coagulation factor VIIa [recombinant]) Bebulin (factor IX complex) Nuwiq (simoctocog alfa) BeneFix (coagulation factor IX [recombinant]) Obizur (antihemophilic factor [recombinant], porcine Coagadex (coagulation factor X [human]) sequence) Corifact (factor XIII concentrate [human]) Profilnine (factor IX complex) Eloctate (antihemophilic factor [recombinant], Fc fusion protein) Rebinyn (coagulation factor IX [recombinant], glycoPEGylated) FEIBA, FEIBA NF (anti-inhibitor coagulant complex) Recombinate (antihemophilic factor [recombi nant]) Fibryga (fibrinogen, human) RiaSTAP (fibrinogen concentrate [human]) Helixate FS (antihemophilic factor [recombinant]) Rixubis (coagulation factor IX [recombinant]) Hemlibra (emicizumab-kxwh) Tretten (coagulation factor XIII a-subunit [recombinant]) Hemofil M (antihemophilic factor [human]) Vonvendi (von Willebrand factor [recombi nant]) Humate-P (antihemophilic factor/von Willebrand factor complex Wilate (von Willebrand factor/coagulation factor VIII complex [human]) [human]) Idelvion (antihemophilic factor [recombinant]) Xyntha, Xyntha Solof (antihemophilic factor [recombinant]) Ixinity (coagulation factor IX [recombinant]) Jivi [antihemophilic factor (recombinant), PEGylated-aucl] Other drugs and medical injectables For the followingservices,providers call1-866-503-0857or fax applicable request forms to 1-888-267-3277, with the following exceptions: • Forprecertification of pharmacy-covered specialty drugs(notedwith*) whenmemberis enrolled in a commercialplan,call 1-855-240-0535 or fax applicable request forms to 1-877-269-9916. • Providers can usethedrug-specificSpecialty Medication Request Form located onlineunder “Specialty Pharmacy Precertification.” • Providers can submit Specialty Pharmacy precertification requests electronically using provider online tools and ® resources at NaviNet drug precertification orCoverMyMeds with Aetna. • Providersshoulduse the contacts below for members enrolled in a Foreign Service Benefit Plan, MHBP or Rural Carrier Benefit Plan: − For precertification of pharmacy-covered specialty drugs — Foreign Service Benefit Plan, call Express Scripts at 1-800-922-8279, MHBP and RuralCarrier Benefit Plan, call CVS/ Caremarkat1-800-237-2767. − For precertification of all other listed drugs — ForeignServiceBenefitPlan,call 1-800-593-2354 MHBP, call 1-800-410-7778; Rural Carrier Benefit Plan, call 1-800-638-8432. Acthar Gel/H. P. Acthar (corticotropin) Enzyme replacement drugs, cont. Adcetris (brentuximab vedotin) Strensiq (asfotase alfa) Alpha 1-proteinase inhibitor (human): Vimizim (elosulfase alfa) Aralast NP (alpha 1-proteinase inhibitor) VPRIV (velaglucerase alfa) Glassia (alpha 1-proteinase inhibitor) Erbitux (cetuximab) Prolastin-C (alpha 1-proteinase inhibitor) Erythropoiesis-stimulating agents: Zemaira (alpha 1- proteinase inhibitor) Aranesp (darbepoetin alfa) Amyotrophic Lateral Sclerosis (ALS) drugs: Epogen (epoetin alfa) Radicava (edaravone) — precertification for the drug and Mircera (epoetin beta) site of care required Procrit (epoetin alfa) Benlysta (belimumab) Retacrit (recombinant human erythropoietin) Besponsa (inotuzumab ozogamicin) Fusilev (levoleucovorin) Botulinum toxins: Gattex (teduglutide) Botox (onabotulinumtoxinA) Gazyva (obinutuzumab) Dysport (abobotulinumtoxinA) Granulocyte-colony stimulating factors: Myobloc (rimabotulinumtoxinB) Fulphila (pegfilgrastim-jmdb) Xeomin (incobotulinumtoxinA) Granix (tbo-filgrastim) Cablivi (caplacizumab-yhdp) – precertification required Leukine (sargramostim) effective 4/17/2019 Neulasta (pegfilgrastim) Calcitonin Gene-RelatedPeptide(CGRP)receptorinhibitors Neupogen (filgrastim) Cardiovascular — PCSK9inhibitors: Nivestym (filgrastim-aafi) Praluent (alirocumab) Udenyca (pegfilgrastim-cbvq) – precertification required Repatha (evolocumab) effective 3/1/2019 Chimeric Antigen Receptor T-Cell Therapy (CAR-T) — Zarxio (filgrastim-sndz) Contact National Medical Excellence at 1-877-212-8811 Growth hormone: Kymriah (tisagenlecleucel) Genotropin* (somatropin) Yescarta (axicabtagene ciloleucel) Humatrope* (somatropin) Crysvita (burosumab) — precertification for the drug Increlex* (mecasermin) and site of care required Norditropin*(somatropin) Cyramza (ramucirumab) Nutropin AQ* (somatropin) Darzalex (daratumumab) Omnitrope* (somatropin) Dupixent* (dupilumab) Saizen* (somatropin) Empliciti (elotuzumab) Serostim* (somatropin) Enzyme replacement drugs: Zomacton* (somatropin [rDNA origin]) Aldurazyme (laronidase) Zorbtive* (somatropin) Brineura (cerliponase alfa) Hepatitis C drugs: Cerezyme (imiglucerase) Daklinza (daclatasvir) Elaprase (idursulfase) Epclusa (sofosbuvir and velpatasvir) Elelyso (taliglucerase alfa) Harvoni (sofosbuvir/ledipasvir) Fabrazyme (agalsidase beta)
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