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).

Services that require precertification: 16. Lower limb prosthetics, such as 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 ) 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) 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 -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) Mavyret (glecaprevir/pibrentasvir) Kanuma (sebelipase alfa) Olysio (simeprevir) Lumizyme (alglucosidase alfa) Sovaldi (sofosbuvir) Mepsevii (vestronidase alfa-vjbk) Technivie (ombitasvir/paritaprevir/ritonavir) Naglazyme (galsulfase) Viekira Pak (paritaprevir/ritonavir/ ombitasvir/dasabuvir) Hepatitis C drugs, cont. Immunologic agents, cont. Viekira XR (ombitasvir/ paritaprevir/ ritonavir and dasabuvir) Siliq* (brodalumab) Vosevi (sofosbuvir/ velpatasvir/ voxilaprevir) Simponi* (golimumab) Zepatier (elbasvir/grazoprevir) Simponi Aria (golimumab) — precertification for the Hereditary angioedema agents: drug and site of care required Berinert (C1 esterase inhibitor) Stelara* (ustekinumab) Cinryze (C1 esterase inhibitor) Stelara IV (ustekinumab) Firazyr (icatibant acetate) Taltz* (ixekizumab) Haegarda (C1 esterase inhibitor subcutaneous [human]) Tremfya* (guselkumab) Kalbitor (ecallantide) Truxima (rituximab-abbs) – precertification required effective Ruconest (C1 esterase inhibitor) 5/15/19 Takhzyro (lanadelumab) Xeljanz,* Xeljanz XR* (tofacitinib) HER2 receptor drugs: Injectable infertility drugs: Herceptin (trastuzumab) chorionic gonadotropin Kadcyla (ado-trastuzumab emtansine) Bravelle (urofollitropin) Perjeta (pertuzumab) Cetrotide (cetrorelix acetate) Ilaris* (canakinumab) Follistim AQ (follitropin beta) Imlygic (talimogene laherparepvec) Ganirelix AC (ganirelix acetate) Immunoglobulins (precertification for the drug and site of Gonal-f (follitropin alfa) care required): Gonal-f RFF (follitropin alfa) Bivigam (immune globulin) Menopur (menotropins) Carimune NF (immune globulin) Novarel (chorionic gonadotropin) Cuvitru (immune globulin SC [human]) Ovidrel (choriogonadotropin alfa) Flebogamma (immune globulin) Pregnyl (chorionic gonadotropin) GamaSTAN S/D (immune globulin) Khapzory (levoleucovorin) – precertification required Gammagard, Gammagard S/D (immune globulin) effective 3/1/2019 Gammaked (immune globulin) Krystexxa (pegloticase) Gammaplex (immune globulin) Lartruvo (olaratumab) Gamunex-C (immune globulin) Lumoxiti (moxetumomab pasudotox-tdfk) Hizentra (immune globulin) Makena (hydroxyprogesterone caproate) HyQvia (immune globulin) Multiple sclerosis drugs: Octagam (immune globulin) Aubagio* (teriflunomi de) Panzyga (immune globulin) Avonex* (interferon beta-1a) Privigen (immune globulin) Betaseron* (interferon beta-1b) Immunologic agents: Copaxone* (glatiramer acetate) Actemra (tocilizumab) — precertification for the drug and Extavia* (interferon beta-1b) site of care required Gilenya* (fingolimod hydrochloride) Actemra* SC (tocilizumab) Glatopa* (glatiramer acetate injection) Cimzia* (certolizumab pegol) Lemtrada (alemtuzumab) — precertification for the drug and Cimzia IV (certolizumab pegol) site of care required Cosentyx* (secukinumab) Mavenclad* (cladribine) – precertification required effective Enbrel* (etanercept) 5/15/2019 Entyvio (vedolizumab) — precertification for the Mayzent* (siponimod) – precertification required effective drug and site of care required 5/15/2019 Humira* (adalimumab) Ocrevus (ocrelizumab) — precertification for the drug Ilumya* (tildrakizumab) and site of care required Inflectra (infliximab-dy yb) — precertification for Plegridy* (peginterferon beta-1a) the drug and site of care required Rebif* (interferon beta-1a) Kevzara* (sarilumab) Tecfidera* (dimethyl fumarate) Kineret* (anakinra) Tysabri (natalizumab) — precertification for the drug and site Olumiant* (baricitinib) of care required Orencia SQ* (abatacept) Muscular dystrophy drugs: Orencia IV (abatacept) — precertification for the Exondys 51 () — precertification for the drug drug and site of care required and site of care required Otezla* (apremilast) Emflaza* (deflazacort) Remicade (infliximab) — precertification for the Myalept (metreleptin) drug and site of care required Natpara (parathyroid hormone) Renflexis (infliximab-abda) — precertification for Onpattro (patisiran) — precertification for the drug and site the drug and site of care required of care required Rituxan (rituximab) Ophthalmic injectables: Respiratory injectables: Eylea (aflibercept) Cinqair (reslizumab) Lucentis (ranibizumab) Fasenra (benralizumab) Luxturna (voretigene neparvovec-rzyl) — Nucala (mepolizumab) precertification for the drug and site of care Xolair (omalizumab) required Soliris (eculizumab) — precertification for the drug and site Macugen (pegaptanib) of care required Osteoporosis drugs: Spinraza () Forteo* (teriparatide) Spravato (esketamine) – precertification required Miacalcin (calcitonin) effective 5/15/2019 Prolia (denosumab) Synagis (palivizumab) Tymlos* (abaloparatide) Tegsedi (inotersen) Parsabiv (etelcalcetide) Ultomiris (Ravulizumab-cwvz) – precertification required PD1/PDL1 drugs: effective 3/15/2019 Bavencio (avelumab) Vectibix (panitumumab) Imfinzi (durvalumab) Viscosupplementation: Keytruda (pembrolizumab) Durolane () Libtayo (cemiplimab-rwlc) Euflexxa, Hyalgan, Genvisc, Supartz, TriVisc, Visco 3 Opdivo (nivolumab) (sodium hyaluronate) Tecentriq (atezolizumab) Gel-One (cross-linked hyaluronate) Provenge (sipuleucel-T) Gelsyn­3, Hymovis (hyaluronic acid) Pulmonary arterial hypertension drugs: Monovisc, Orthovisc (sodium hyaluronate) All epoprostenol sodium and sildenafil citrate* Synvisc, Synvisc-One (hylan) Adcirca* (tadalafil) Xgeva (denosumab) Adempas* (riociguat) Xofigo (radium Ra 223 dichloride) Flolan (epoprostenol sodium) Yervoy (ipilimumab) Letairis* (ambrisentan) Opsumit* (macitentan) Orenitram* (treprostinil diolamine) Remodulin (treprostinil sodium) Revatio* (sildenafil citrate) Tracleer* (bosentan) Tyvaso (treprostinil) Uptravi* (selexipag) Veletri (epoprostenol sodium) Ventavis (iloprost) Special programs BRCA genetic testing — 1-877-794-8720 Diagnostic Cardiology (cardiac rhythm implantable See #9 in the General information section for additional devices, cardiac catheterization) guidance. See #9 in the General information section for additional Through our expanded national provider network: guidance. • Quest — 1-866-436-3463 Precertification for all members with plans applicable Ambry — • 1-866-262-7943 to this precertification list unless services are • Baylor Miraca Genetics Laboratories, LLC— emergent: 1-800-411- GENE or 1-713-798-6555 • Providers in all states where applicable, except New York • BioReference, GeneDX, Genpath —1-888-729-1206 and northern New Jersey, should contact MedSolutions • Counsyl — 1-888-268-6795 DBA eviCore healthcare to request preauthorization on. • Invitae — 1-800-436-3037 You can reach MedSolutions DBA eviCore healthcare: • LabCorp — 1-855-488-8750 - Online atevicore.com • Medical Diagnostic Laboratories —1-877-269-0090 - By phone at 1-888-693-3211 between 7 a.m. and 8 Myriad Genetics — • 1-800-469-7423 p.m. ET Providers can use the BRCA form located online - By fax at 1- 844 -822-3862, Monday through under the “Medical Precertification” section to Friday during normal business hours, or as submit precertification requests. required by federal or state regulations Find genetic counselors online — for a list of our • Providers in New York and northern New Jersey contracted providers, including our telephonic provider should contact CareCore National DBA eviCore (Informed DNA), visit our provider directory. healthcare to request preauthorization. You can reach Chiropractic precertification CareCore National DBA eviCore healthcare: See #9 in the General information section for additional - Online at evicore.com guidance. - By phone at 1-888-622-7329 for New York or 1-888-647-5940 for northern New Chiropractic precertification required only in the states Jersey listed HMO-based plan members only Hip and knee arthroplasties • AZ through American Specialty Health (ASH)1- 800- 972-4226 See #9 in the General information section for additional guidance. HMO-based plan and group Medicare members only • CA through American Specialty Health(ASH)1- Precertification for all members with plans applicable to 800- 972-4226 this precertification list unless services are emergent: For all members (with commercial and Aetna • Providers in all states where applicable, except New York Medicare Advantage plans applicable to this and northern New Jersey, should contact MedSolutions precertification list): DBA eviCore healthcare to request preauthorization on. • GA through American Specialty You can reach MedSolutions DBA eviCore healthcare: Health(ASH)1- 800- 972-4226 - Online at evicore.com - By phone at between 7 a.m. For all members (with certain commercial plans, and Aetna 1-888-693-3211 Medicare Advantage plans, applicable to this and 8 p.m.ET precertification list) – - By fax at 1- 844 -822-3862, Monday through Friday during normal business hours, or as • DE, NJ,NY,PA, WV: through National Imaging required by federal or state regulations Associates 1-866-842-1542 • Providers in New York and northern New Jersey should contact CareCore National DBA eviCore healthcare to request preauthorization. You can reach CareCore National DBA eviCore healthcare: - Online at evicore.com - By phone at 1-888-622-7329 for New York or 1-888- 647-5940 for northern New Jersey Infertility program — 1-800-575-5999 See #9 in the General information section for additional guidance. Mental health or substance abuse services precertification— See the member’s ID card See #9 in the General information section for additional guidance. Special programs, continued National Medical Excellence Program Polysomnography (attended sleep studies) See #9 in the General information section for additional guidance. By phone at 1-877-212-8811 for the following: Precertification for all members with plans applicable to • Kymriah (tisagenlecleucel) and Yescarta (axicabtagene ciloleucel) this precertification list when performed in any • All major organ transplant evaluations and facility except inpatient, emergency room and observation bed status transplants including, but not limited to, kidney, liver, heart, lung and pancreas, and bone marrow • Providers in all states where applicable, except New York replacement or stem cell transfer after high-dose and northern New Jersey, should contact MedSolutions DBA chemotherapy eviCore healthcare to request preauthorization. You can Outpatient physical therapy (PT) and occupational reach MedSolutions DBA eviCore healthcare: therapy (OT) precertification - Online at evicore.com See #9 in the General information section for additional - By phone at 1-888-693-3211 between 7 a.m. and 8 p.m. ET guidance. - By fax at 1- 844 -822-3862, Monday through Through OrthoNet 1-800 -771-3205 Friday during normal business hours, or as • CT— for all members with plans applicable to required by federal or state regulations this precertification list • Providers in New York and northern New Jersey should Through Optum Health 1-800-344-4584 (only Optum contact CareCore National DBA eviCore healthcare to Health/Aetna-contracted providers should call this request preauthorization. You can reach CareCore National number for questions and service requests) DBA eviCore healthcare: • DC,GA,NC, SC, VA — For all members with - Online at evicore.com plans applicable to this precertification list - By phone at 1-888-622-7329 for New York or • Program also applies to members in Chicago, 1-888- 647-5940 for northern New Jersey northern IL and northwest IN (Lake and Porter Pre-implantation genetic testing — 1-800-575-5999 counties) See #9 in the General information section for additional guidance. Through National Imaging Associates 1-866-842-1542 Radiology imaging • DE, NJ, NY, PA, WV for members with certain commercial plans, and Aetna Medicare See #9 in the General information section for additional guidance. Advantage plans, applicable to this Precertification for all members with plans applicable to this precertification list precertification list when performed in any facility except inpatient, emergency room and observation bed status. Pain management • Providers in all states where applicable, except New York and See #9 in the General information section for additional northern New Jersey, should contact MedSolutions DBA guidance. eviCore healthcare to request preauthorization. You can reach Precertification for all members with plans applicable to this MedSolutions DBA eviCore healthcare: precertification list unless services are emergent. - Online at evicore.com • Providers in all states where applicable, except - By phone at 1-888-693-3211 between 7 a.m.and8 New York and northern New Jersey, should contact p.m. ET MedSolutions DBA eviCore healthcare to request - By fax at 1-844-822-3862, Monday through Friday during preauthorization on. You can reach MedSolutions normal business hours or as required by federal or state DBA eviCore healthcare: regulations - Online at evicore.com • Providers in New York and northern New Jersey should - By phone at 1-888-693-3211 between 7 a.m. and 8 contact CareCore National DBA eviCore healthcare to request p.m. ET preauthorization. You can reach CareCore National DBA - By fax at 1-844 -822-3862, Monday eviCore healthcare: through Friday during normal business - Online atevicore.com hours, or as required by federal or - By phone at 1-888-622-7329 New York or 1-888-647-5940 state regulations for northern New Jersey • Providers in New York and northern New Jersey should contact CareCore National DBA eviCore healthcare to request preauthorization. You can reach CareCore National DBA eviCore healthcare: - Online at evicore.com - By phone at 1-888-622-7329 for New York or 1-888-647-5940 for northern New Jersey Special programs, continued Radiation oncology See #9 in the General information section for additional guidance. Precertification for all members with HMO-based and Aetna Medicare Advantage plans only when performed in any facility except inpatient, emergency room and observation bed status. • Providers in New York and northern New Jersey should contact CareCore National DBA eviCore healthcare to request preauthorization. You can reach CareCore National DBA eviCore healthcare: - Online at evicore.com - By phone at 1-888-622-7329 for metro and upstate New York or 1-888-647-5940 for northern New Jersey General information

1. We collect information before elective inpatient • If member eligibility and plan coverage for the admissions and/or selected ambulatory procedures procedure/ service you asked for hasn’t changed, and services at the time of precertification. precertification approvals are valid for six months in all • We’ll review precertification requests using one of states. This is the case unless we tell you otherwise the following processes as long as the member’s when you receive the precertification decision. plan covers the services: • Every year, in January and July, we typically update the a. Notification is a data-entry process. It doesn’t precertification list. But we may add new U.S. Food and require judgment or interpretation for Drug Administration (FDA)-approved drugs to the list at benefits coverage. different times. b. Medical review- coverage determinations made for • Visit Clinical Policy Bulletins and our items on the precert list are utilization review online provider directory. decisions. We review plan document s and (when • The precertification process doesn’t include verbal or applicable) clinical information. This is how we written requests for information about benefits or determine whether the requested service, services not on the precertification lists. Our staff procedure, or medical device members are educated to determine whether a caller is meets the clinical guidelines/criteria for coverage. making an inquiry or requesting a coverage • We need to receive requests for precertification decision/organization determination as part of the before you provide services. intake process. c. We encourage providers to submit • Find more information about notification precertification requests at least two weeks and coverage determinations. before the scheduled services. 2. We don’t offer all plans in all service areas, and not d. To save you time, it’s best to submit all plans include all services listed. For example, precertification requests and inquiries precertification programs don’t apply to fully insured electronically. This is the quickest way to receive members in Indiana. an authorization for services requiring 3. Innovation Health Insurance Company and Innovation precertification. If you need help, just call us. Health Plan, Inc. (Innovation Health) are affiliates of Look for the “precertification” number on the Aetna Life Insurance Company (Aetna) and its member’s ID card. affiliates. Aetna and its affiliates provide certain e. If you don’t precertify the services on this list, the management services for Innovation Health. member’s health plan (the “health plan”), 4. We require precertification when Aetna or Innovation employer group or member won’t be financially Health is the secondary payer. responsible for the applicable service(s) if you still 5. We require precertification for maternity and provide those services. newborn stays that are more than the standard • This material is for your information only. It’s not length of stay (LOS). Standard LOS for: meant to direct treatment decisions. • Vaginal deliveries is three days or fewer • The review of items on this list may vary at our • Cesarean section is five days or fewer discretion. If you receive approval for a particular 6. All services described as “never effective” are excluded service or supply, it’s for that service or supply from coverage. Aetna defines a service as “never only. effective” when it’s not recognized according to • Services that don’t require precertification are professional standards of safety and effectiveness in subject to the coverage terms of the member’s the United States for diagnosis, care or treatment. Visit plan. aetna.com for more information. Select “Claims,” • For precertification in Texas, we use the utilization “CPT/HCPCS Coding Tool” and “Clinical Policy Code review process to determine whether the requested Lookup.” service, procedure, prescription drug or medical device meets the company’s clinical criteria for coverage. Precertification doesn’t mean payment for care or services to fully insured HMO and PPO members as defined by Texas law. General information, continued

7. Contact Aetna Pharmacy Management for 9. For members enrolled in Foreign Service Benefit Plan, precertification of oral medications not on this list. MHBP or Rural Carrier Benefit Plan: Precertification is • See #9 in General information section for additional not required for cardiac catheterization, cardiac guidance. imaging, chiropractic services, transthoracic • Their number is 1-800-414-2386 echocardiogram or physical/occupational therapy • Call 1-866-782-2779 for information on injectable • Visit online provider directories: Foreign Service medications not listed BenefitPlan ; MHBP; Rural Carrier Benefit Plan 8. For drugs administered orally, by injection or infusion: • Except as noted for drugs and medical injectables and special programs, for all • Drugs newly approved by the FDA other services: may require precertification review − Foreign Service BenefitPlan , call 1-800- • Fully insured Texas and Louisiana members 593- 2354 continue to be covered for drugs added to the precertification list according to their current plan − MHBP, call 1-800- 410 -7778 design until their plan renewal date − Rural Carrier BenefitPlan , call 1-800 - • Fully insured California HMO members and fully 638- 8432 insured Connecticut PPO members covered for drugs added to the precertification list continue to have coverage a. Drug coverage continues for these California members as long as the drug is appropriately prescribed and considered safe and effective treatment for the medical condition b. Drug coverage continues for these Connecticut members as long as the drug is medically necessary and more medically beneficial than other covered drugs • The prescribing provider must respond to requests for more information. For fully insured members with a Colorado state contract, we’ll approve or deny precertification requests within time frames mandated by Colorado Regulation 4-2-49 RX Prior Authorization.

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.

aetna.com © 2019 Aetna Inc. 23.03.882.1 X (5/19)