Procedures, programs and drugs that require precertification

Participating provider precertification list

Starting October 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 plans offered and/or underwritten by Innovation Health plans, Inc., and Innovation 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 V (10/21)

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) 19. 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 20. 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 21. Osseointegrated implant fixed- wing aircraft (plane) 22. Osteochondral allograft/knee 3. Arthroscopic hip surgery to repair impingement 23. Private duty nursing syndrome including labralrepair 24. Proton beam radiotherapy 4. Autologous chondrocyte implantation Also see Special Programs; Radiation Oncology 5. Cataract surgery – precertification required 25. Reconstructive or other procedures thatmaybe effective 7/1/2021. See special programs for considered cosmetic, such as: additional guidance. • Blepharoplasty/canthoplasty 6. Chiari malformation decompression surgery • Breast reconstruction/breast enlargement 7. Cochlear device and/or implantation • Breast reduction/mammoplasty 8. Coverage at an in-network benefit level • Excision of excessive skin due to weight loss for out-of-network provider or facility • Gastroplasty/gastric bypass unless services are emergent. • Lipectomy or excess fat removal Some plans have limited or no out-of­network • Surgery for varicose veins, except stab phlebectomy benefits. 26. Shoulder Arthroplasty includingrevision 9. Dental implants procedures 10. Dialysis visits 27. Spinal procedures, such as: When a participating provider initiates a • Artificial intervertebral disc surgery (cervical spine) request and dialysis is to be performed at a • Arthrodesis for spine deformity nonparticipating facility. • Cervical laminoplasty 11. Dorsal column (lumbar) neurostimulators: • Cervical, lumbar and thoracic laminectomy and\or trial or implantation laminotomy procedures 12. Electric or motorized wheelchairs and • Kyphectomy scooters • Laminectomy with rhizotomy 13. Endoscopic nasal balloon dilation procedures • Spinal fusion surgery – precertification required for 14. Functional endoscopic sinus surgery (FESS) sacroiliac joint fusion surgery effective 7/1/2021 15. Gender affirmation surgery • Vertebral corpectomy – precertification is required 16. Hyperbaric oxygen therapy effective 7/1/2021. 17. Infertility services and pre-implantation 28. Uvulopalatopharyngoplasty, genetic testing including laser- assisted procedures 18. Lower limb prosthetics, such as 29. Ventricular assist devices microprocessor-controlled lower limb 30. Video electroencephalograph (EEG) prosthetics 31. Whole exome sequencing

Proprietary

Drugs and medical injectables

Blood clotting factors (precertification for outpatientinfusion 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 -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], PEGylated) Jivi [antihemophilic factor (recombinant), 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 (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 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, 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. 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 Botulinum toxins, cont. members only Xeomin (incobotulinumtoxinA) Acthar Gel/H. P. Acthar (corticotropin) Cablivi (caplacizumab-yhdp) Adakveo (crizanlizumab-tmca) – precertification for Calcitonin Gene-Related Peptide (CGRP) receptor the drug and site of care required inhibitors Adcetris (brentuximab vedotin) Vyepti (eptinezumab-jjmr) — precertification for the Aduhelm (aducanumab-avwa) — precertification for drug and site of care required drug and site of care required effective 8/3/2021 Cardiovascular — PCSK9 inhibitors: Alpha 1-proteinase inhibitor (human) Praluent* (alirocumab) (precertification for the drug and site of care required): Repatha* (evolocumab) Aralast NP (alpha 1-proteinase inhibitor) Chimeric Antigen Receptor T-Cell Therapy (CAR-T) Glassia (alpha 1-proteinase inhibitor) — Contact National Medical Excellence at Prolastin-C (alpha 1-proteinase inhibitor) 1-877-212-8811 Zemaira (alpha 1- proteinase inhibitor) Abecma (idecabtagene vicleucel) — Amyotrophic Lateral Sclerosis (ALS) drugs: precertification required effective 6/1/2021 Radicava (edaravone) — precertification for the Breyanzi (lisocabtagene maraleucel) — precertification required effective 5/7/2021 drug and site of care required Kymriah (tisagenlecleucel) Avastin (bevacizumab), 10 mg — precertification required for oncology indications only Tecartus (brexucabtagene autoleucel) Aveed (testosterone undecanoate) Yescarta (axicabtagene ciloleucel) Belrapzo (bendamustine HCl) Cosela (trilaciclib) — precertification required effective 5/7/2021 Bendeka (bendamustine HCl) Crysvita (burosumab) — precertification for the Benlysta (belimumab) — precertification for the drug and site of care required drug and site of care required Cyramza (ramucirumab) Besponsa (inotuzumab ozogamicin) Blenrep (belantamab mafodotin-blmf) Danyelza (naxitamab-gqgk) — precertification required effective 3/1/2021 Bortezomib — precertification required effective 9/1/2021 for multiple myeloma only Darzalex (daratumumab) Botulinum toxins: Darzalex Faspro (daratumumab and hyaluronidase-fihj) Botox (onabotulinumtoxinA) Dysport (abobotulinumtoxinA) Dupixent* (dupilumab) Myobloc (rimabotulinumtoxinB) Empliciti (elotuzumab) Proprietary

Enzyme replacement drugs: Granulocyte-colony stimulating factors, cont. Aldurazyme (laronidase) — precertification Neulasta (pegfilgrastim) for the drug and site of care required Neupogen (filgrastim) Brineura (cerliponase alfa) Nivestym (filgrastim-aafi) Cerezyme (imiglucerase) — precertification for Nyvepria (pegfilgrastim-apgf) — precertification the drug and site of care required. required effective 2/1/2021 Elaprase (idursulfase) — precertification Udenyca (pegfilgrastim-cbvq) for the drug and site of care required Zarxio (filgrastim-sndz) Elelyso (taliglucerase alfa) — precertification for the drug and site of Ziextenzo (pegfilgrastim-bmez) care required Growth hormone: Fabrazyme (agalsidase beta) — Genotropin* (somatropin) precertification for the drug and site of Humatrope* (somatropin) care required Increlex* (mecasermin) Kanuma (sebelipase alfa) — precertification for the Norditropin*(somatropin) drug and site of care required Nutropin AQ* (somatropin) Lumizyme (alglucosidase alfa) — precertification Omnitrope* (somatropin) for the drug and site of care required Saizen* (somatropin) Mepsevii (vestronidase alfa-vjbk) — precertification Serostim* (somatropin) for the drug and site of care required Sogroya* (somapacitan-beco) – precertification Naglazyme (galsulfase) — precertification for required effective 2/11/2021 the drug and site of care required Zomacton* (somatropin [rDNA origin]) Nexviazyme (avalglucosidase alfa-ngpt) — Zorbtive* (somatropin) precertification for the drug and site of care required effective 10/7/2021 Hereditary angioedema agents: Strensiq (asfotase alfa) Berinert (C1 esterase inhibitor) Vimizim (elosulfase alfa) — precertification for Cinryze (C1 esterase inhibitor) – precertification for the drug and site of care required the drug and site of care required VPRIV (velaglucerase alfa) — precertification Firazyr (icatibant acetate) for the drug and site of care required Haegarda (C1 esterase inhibitor subcutaneous Erbitux (cetuximab) [human]) Erythropoiesis-stimulating agents: Kalbitor (ecallantide) Aranesp (darbepoetin alfa) Ruconest (C1 esterase inhibitor) Takhzyro (lanadelumab) Epogen (epoetin alfa) HER2 receptor drugs: Mircera (epoetin beta) Enhertu (fam-trastuzumab deruxtecan-nxki) Procrit (epoetin alfa) Herceptin (trastuzumab) Retacrit (recombinant human erythropoietin) Herceptin Hylecta (trastuzumab and Evkeeza (evinacumab-dgnb) — precertification hyaluronidase-oysk) for the drug and site of care required effective 5/7/2021 Herzuma (trastuzumab-pkrb) Evrysdi (risdiplam) Kadcyla (ado-trastuzumab emtansine) Kanjinti (trastuzumab-anns) Feraheme (ferumoxytol) Margenza (margetuximab-cmkb) – precertification Fusilev (levoleucovorin) required effective 4/1/2021 Gattex (teduglutide) Ogivri (trastuzumab-dkst) Givlaari (givosiran) – precertification for drug Ontruzant (trastuzumab-dttb) and site of care required Perjeta (pertuzumab) Granulocyte-colony stimulating factors: Phesgo (pertuzumab/trastuzumab/hyaluronidase­ Fulphila (pegfilgrastim-jmdb) zzxf) Granix (tbo-filgrastim) Trazimera (trastuzumab-qyyp) Leukine (sargramostim)

Ilaris* (canakinumab) Immunologic agents, cont. Imlygic (talimogene laherparepvec) Riabni (rituximab-arrx) — precertification required Immunoglobulins (precertification for the drug effective 4/2/2021 and site of care required): Rinvoq (upadacitinib) Asceniv (immune globulin) Rituxan (rituximab) Bivigam (immune globulin) Rituxan Hycela (rituximab/hyaluronidase human) Carimune NF (immune globulin) Ruxience (rituximab-pvvr) Cutaquig (immune globulin) Siliq* (brodalumab) Cuvitru (immune globulin SC [human]) Simponi* (golimumab) Flebogamma (immune globulin) Simponi Aria (golimumab) — precertification for GamaSTAN S/D (immune globulin) the drug and site of care required Gammagard, Gammagard S/D (immune globulin) Skyrizi* (risankizumab-rzaa) Gammaked (immune globulin) Stelara* (ustekinumab) Gammaplex (immune globulin) Stelara IV (ustekinumab) Gamunex-C (immune globulin) Taltz* (ixekizumab) Hizentra (immune globulin) Tremfya* (guselkumab) HyQvia (immune globulin) Truxima (rituximab-abbs) Octagam (immune globulin) Xeljanz*, Xeljanz XR* (tofacitinib) Panzyga (immune globulin) Injectable infertility drugs: Privigen (immune globulin) chorionic gonadotropin Xembify (immune globulin) Bravelle (urofollitropin) Immunologic agents: Cetrotide (cetrorelix acetate) Avsola (infliximab-axxq) — precertification Follistim AQ (follitropin beta) for the drug and site of care required Ganirelix AC (ganirelix acetate) Actemra (tocilizumab) — precertification for Gonal-f (follitropin alfa) the drug and site of care required Gonal-f RFF (follitropin alfa) Actemra* SC (tocilizumab) Menopur (menotropins) Cimzia* (certolizumab pegol) Novarel (chorionic gonadotropin) Cosentyx* (secukinumab) Ovidrel (choriogonadotropin alfa) Enbrel* (etanercept) Pregnyl (chorionic gonadotropin) Enspryng* (satralizumab) Injectafer (ferric carboxymaltose injection) Entyvio (vedolizumab) — precertification for the Jelmyto (mitomycin) drug and site of care required Khapzory (levoleucovorin) Humira* (adalimumab) Kyprolis (carfilzomib) — precertification required Ilumya* (tildrakizumab) effective 9/1/2021 for multiple myeloma only Inflectra (infliximab-dyyb) — precertification for Lartruvo (olaratumab) the drug and site of care required Luteinizing hormone-releasing hormone Kevzara* (sarilumab) (LHRH) agents: Kineret* (anakinra) Camcevi (leuprolide mesylate) — precertification Olumiant* (baricitinib) required effective 8/1/2021 Orencia SQ* (abatacept) Eligard (leuprolide acetate) Orencia IV (abatacept) — precertification Firmagon (degarelix) for the drug and site of care required Lupron Depot (leuprolide acetate), 7.5 mg — Otezla* (apremilast) precertification required for oncology Remicade (infliximab) — precertification indications only for the drug and site of care required Trelstar (triptorelin pamoate) Renflexis (infliximab-abda) — precertification Zoladex (goserelin) for the drug and site of care required Lumoxiti (moxetumomab pasudotox-tdfk)

Makena (hydroxyprogesterone caproate) Ophthalmic injectables, cont. Monjuvi (tafasitamab-cxix) Eylea (aflibercept) Multiple sclerosis drugs: Lucentis (ranibizumab) Aubagio* (teriflunomide) Luxturna (voretigene neparvovec-rzyl) — Avonex* (interferon beta-1a) precertification for the drug and site of care Bafiertam* (monomethyl fumarate) required Betaseron* (interferon beta-1b) Macugen (pegaptanib) Copaxone* (glatiramer acetate) Tepezza (teprotumumab-trbw) – precertification for the drug and site of care required Extavia* (interferon beta-1b) Osteoporosis drugs: Gilenya* (fingolimod hydrochloride) Bonsity* (teriparatide) Glatopa* (glatiramer acetate injection) Evenity* (romosozumab-aqqg) Kesimpta* (ofatumumab) Forteo* (teriparatide) Lemtrada (alemtuzumab), — precertification for the drug and site of care required Miacalcin (calcitonin) Mavenclad* (cladribine) Prolia (denosumab) Mayzent* (siponimod) Tymlos* (abaloparatide) Ocrevus (ocrelizumab) — precertification for Oxlumo (lumasiran) — precertification for the drug the drug and site of care required and site of care required effective 3/17/2021 Plegridy* (peginterferon beta-1a) Padcev (enfortumab vedotin) Ponvory* (ponesimod) — precertification Parsabiv (etelcalcetide) required effective 5/1/2021 PD1/PDL1 drugs (precertification for the drug Rebif* (interferon beta-1a) and site of care required): Tecfidera* (dimethyl fumarate) Bavencio (avelumab) Tysabri (natalizumab) — precertification for Imfinzi (durvalumab) the drug and site of care required Jemperli (dostarlimab-gxly) — precertification for Vumerity* (diroximel fumarate) the drug and site of care required effective 7/1/2021 Zeposia* (ozanimod) Keytruda (pembrolizumab) Muscular dystrophy drugs: Libtayo (cemiplimab-rwlc) Amondys 45 (casimersen) — precertification for the drug and site of care required Opdivo (nivolumab) effective 6/1/2021 Tecentriq (atezolizumab) Exondys 51 (eteplirsen) — precertification Pepaxto (melphalan flufenamide) — precertification for the drug and site of care required required effective 6/1/2021 Emflaza* (deflazacort) Polivy (polatuzumab vedotin-piiq) Viltepso (viltolarsen) — precertification for Provenge (sipuleucel-T) the drug and site of care required Pulmonary arterial hypertension drugs: Vyondys 53 (golodirsen) — precertification All epoprostenol sodium and sildenafil citrate* for the drug and site of care required Adcirca* (Alyq, tadalafil) Mvasi (bevacizumab-awwb) — precertification Adempas* (riociguat) required for oncology indications only Flolan (epoprostenol sodium) Myalept (metreleptin) Letairis* (ambrisentan) Natpara (parathyroid hormone) Opsumit* (macitentan) Nulibry (fosdenopterin) — precertification Orenitram* (treprostinil diolamine) required effective 6/1/2021 Remodulin (treprostinil sodium) Onpattro (patisiran) — precertification for Revatio* (sildenafil citrate) the drug and site of care required Tracleer* (bosentan) Ophthalmic injectables: Tyvaso (treprostinil) Beovu (brolucizumab-dbll) Uptravi* (selexipag)

Pulmonary arterial hypertension drugs, cont. Ultomiris (Ravulizumab-cwvz) — Veletri (epoprostenol sodium) precertification for the drug and site of care required Ventavis (iloprost) Uplizna (inebilizumab-cdon) — precertification Reblozyl (luspatercept) for the drug and site of care required Respiratory injectables (precertification required and site of care required): Vectibix (panitumumab) Velcade (bortezomib) — precertification Cinqair (reslizumab) required effective 9/1/2021 for multiple Fasenra (benralizumab) myeloma only Nucala (mepolizumab) Viscosupplementation: Xolair (omalizumab) Durolane (Hyaluronic acid) Rybrevant (amivantamab-vmjw) — Euflexxa, Hyalgan, Genvisc, Supartz FX, precertification required effective 8/6/2021 TriVisc, Visco 3 (sodium hyaluronate) Ryplazim (plasminogen, human-tvmh) — Gel-One (cross-linked hyaluronate) precertification required effective 8/1/2021 Gelsyn­3, Hymovis (hyaluronic acid) Saphnelo (anifrolumab-fnia) — precertification Monovisc, Orthovisc (sodium hyaluronate) for the drug and site of care required effective 10/7/2021 Synojoynt, Triluron (1% sodium hyaluronate) Sarclisa (isatuximab-irfc) Synvisc, Synvisc-One (hylan) Soliris (eculizumab) — precertification for the Xgeva (denosumab) drug and site of care required Xofigo (radium Ra 223 dichloride) Somatostatin agents: Yervoy (ipilimumab) — precertification for the drug Bynfezia (octreotide) and site of care required Sandostatin (octreotide) Zirabev (bevacizumab-bvzr) — precertification required for oncology indications only Sandostatin LAR (octreotide acetate) Zolgensma (onasemnogene abeparvovec-xioi) – Signifor (pasireotide) precertification for the drug and site of care Signifor LAR (pasireotide) required Somatuline (lanreotide) Zulresso (brexanolone) Somavert (pegvisomant) Zynlonta (loncastuximab tesirine-lpyl) — Spinraza (nusinersen) — precertification precertification required effective 7/1/2021 required and effective 7/1/2021 site of care

required Spravato (esketamine) Synagis (palivizumab) Tegsedi (inotersen) Treanda (bendamustine HCl) Trodelvy (sacituzumab govitecan-hziy)

Special programs, continued

BRCA genetic testing — 1-877-794-8720 Cataract surgery See #9 in the General information section for For all Georgia Medicare only (HMO and PPO) more guidance. cataract surgery related requests, providers should Through our expanded national provider network: contact iCare Health Solutions to request • Quest — 1-866-436-3463 preauthorization. You can reach iCare at 1-844-210-7444. • Ambry — 1-866-262-7943 For all Florida Medicare only (HMO and POS) cataract • Baylor Miraca Genetics Laboratories, LLC— surgery related requests, providers should contact 1-800-411- GENE (1-800-411-4363) • BioReference, GeneDX, Genpath— iCare Health Solutions to request preauthorization. 1-888-729-1206 You can reach iCare at • Invitae — 1-800-436-3037 1-855-373-7627. • LabCorp — 1-855-488-8750 • Medical Diagnosti c Laboratories—1-877 -2 69-0090 Diagnostic Cardiology (cardiac rhythm implantable • Myriad Genetics —1-800-469-7423 devices, cardiac catheterization) • Progenity — 1-855-293-2639 See #9 and #10 in the General information Providers can use the BRCA form located online section for more guidance. under the “Medical Precertification” section to Precertification for all members with plans submit precertification requests. applicable to this precertification list

unless services are emergent: Find genetic counselors online • Providers in all states where applicable, For a list of our contracted providers, including our except New York and northern New telephonic provider (Informed DNA), visit our Jersey, should contact MedSolutions DBA provider directory. eviCore healthcare to request

preauthorization. You can reach Chiropractic precertification MedSolutions DBA eviCore healthcare: See #9 in the General information section for - Online at evicore.com additional guidance. - By phone at 1-888-693-3211 between7 AM Chiropractic precertification required only in the and 8 PM ET states listed HMO-based plan members only - By fax at 1-844-822-3862, Monday AZ through American Specialty Health through Friday during normal (ASH)1-800-972-4226 business hours, or as required HMO-based plan and group Medicare members only by federal or state regulations CA through American Specialty Health • Providers in New York and northern (ASH)1-800-972-4226 New Jersey should contact CareCore For all members (with commercial and Aetna Medicare National DBA eviCore healthcare to Advantage plans applicable to this precertification list): request preauthorization. You can reach CareCore National DBA eviCore GA through American Specialty Health healthcare: (ASH) 1-800-972-4226 - Onlineat evicore.com For all members (with certain commercial plans, and - By phone at 1-888-622-7329 for New York or Aetna Medicare Advantage plans, applicable to this 1-888-647-5940 for northern New Jersey precertification list): DE, NJ, NY, PA, WV: through National Imaging Associates 1-866-842-1542

Special programs, continued Hip and knee arthroplasties National Medical Excellence Program Note: Effective 08/30/2021 these procedures By phone at 1-877-212-8811 for the following: codes will be handled by Aetna/CVS and no • Abecma (idecabtagene vicleucel), Breyanzi longer handled by eviCore. (lisocabtagene maraleucel), Kymriah (tisagenlecleucel), Tecartus (brexucabtagene See #9 and #10 in the General information autoleucel) and Yescarta (axicabtagene section for more guidance. ciloleucel) Precertification for all members with plans • All major organ transplant evaluations and applicable to this precertification list unless transplants including, but not limited to, kidney, services are emergent. liver, heart, lung and pancreas, and bone marrow replacement or stem cell transfer after high-dose

chemotherapy Home health care

All Texas, Georgia, Virginia, and Oklahoma Medicare Advantage (excluding Oklahoma and Virginia Dual Outpatient physical therapy (PT) and occupational Special Needs Plans) home health-related requests for in- therapy (OT) precertification home skilled nursing, physical therapy, occupational See #9 and #10 in the General information section for therapy, speech therapy, a home health aide and medical additional guidance. social work will require precertification through Through OrthoNet 1-800-771-3205 myNEXUS. • CT— for all members with plans applicable Providersin thesestates should contactmyNEXUSto to this precertification list request precertification Through Health 1-800-344-4584 (Only • Go to Portal.myNEXUScare.com/Account/Login Optum Health/Aetna-contracted providers (registration is required). should call this number for questions and service • Fax the form to 1-866-996-0077 requests.) • Questions? Call myNEXUS Intake at • DC, GA, NC, SC, VA — For all members with • 1-833-585-6262 from 8 AM to 8 PM ET, Monday plans applicable to this precertification list through Friday or • Program also applies to members in Chicago, northern • Go to http://www.mynexuscare.com/aetna for IL and northwest IN (Lake and Porter counties) more details • Through National Imaging Associates 1-866-842- 1542 Infertility program — 1-800-575-5999 • DE, NJ, NY, PA, WV for members with certain See #9 in the General information section for additional guidance. commercial plans, and Aetna Medicare Advantage plans, applicable to this precertification list

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 Pain management Polysomnography (attended sleep studies), cont. See #9 and #10 in the General information section for • Providers in New York and northern New Jersey should additional guidance. contact CareCore National DBA eviCore healthcare to Precertification for all members with plans applicable request preauthorization. You can reach CareCore National DBA eviCore healthcare: to this precertification list unless services are - Online at evicore.com emergent. - By phone at 1-888-622-7329 for New York or • Providers in all states where applicable, 1-888-647-5940 for northern New Jersey except New York and northern New Jersey, should contact MedSolutions DBA eviCore Pre-implantation genetic testing — healthcare to request preauthorization on. 1-800-575-5999 You can reach MedSolutions DBA eviCore See #9 in the General information section for healthcare: more guidance. - Online at evicore.com - By phone at 1-888-693-3211between 7 AM and 8 PM ET Radiology imaging - By fax at 1-844 -822-3862, Monday through See #9 and #10 in the General information Friday, during normal business section for more guidance. Precertification for all hours, or as required by federal members with plans applicable to this or state regulations precertification list when performed in any facility • Providers in New York and northern New except inpatient, emergency room and Jersey should contact CareCore National observation bed status. DBA eviCore healthcare to request • Providers in all states where applicable, preauthorization. You can reach except New York and northern New Jersey, CareCore National DBA eviCore should contact MedSolutions DBA eviCore healthcare: healthcare to request preauthorization. - Online at evicore.com You can reach MedSolutions DBA eviCore - By phone at 1-888-622-7329 for New York or healthcare: 1-888-647-5940 for northern New Jersey - Online at evicore.com - By phone at 1-888-693-3211 between7 AM and 8 Polysomnography (attended sleep studies) PM ET See #9 and #10 in the General information section for - By fax at 1-844-822-3862, Monday more guidance. through Friday during normal business Precertification for all members with plans hours or as required by federal or state applicable to this precertification list when regulations performed in any • Providers in New York and northern New facility except inpatient, Jersey should contact CareCore National DBA emergency room and observation eviCore healthcare to request preauthorization. bed status You can reach CareCore National DBA • Providers in all states where applicable, eviCore healthcare: except New York and northern New - Online at evicore.com Jersey, should contact MedSolutions - Byp hone at 1-888-622-7329 New York or DBA eviCore healthcare to request 1-888-647-5940 for northern New Jersey preauthorization. You can reach MedSolutions DBA eviCore healthcare: - Online at evicore.com - By phone at 1-888-693-3211 between 7 AM and 8 PM ET - By fax at 1- 844 -822-3862, Monday through Friday during normal business hours, or as required by federal or state regulations

Special programs, continued Radiation oncology Whole Exome Sequencing (WES) • Complex Through our expanded national provider network: • 3D Conformal • Quest — 1-866-436-3463 • Stereotactic Radiosurgery (SRS) • Ambry — 1-866-262-7943 • Stereotactic Body • Baylor Miraca Genetics Laboratories, LLC — Radiation Therapy 1-800-411- GENE (1-800-411-4363) (SBRT) • BioReference, GeneDX, Genpath — 1-888-729-1206 • Image Guided Radiation Therapy • Invitae — 1-800-436-3037 (IGRT) • LabCorp — 1-866-248-1265 • Intensi ty -Mo dul ated Providers can use the Whole Exome Sequencing Radiation Therapy (IMRT) (WES) form located online under the “Medical • Proton Beam Therapy Precertification” section to submit precertification • Neutron Beam Therapy requests. • Brachytherapy • Hyperthermia • Radiopharmaceuticals

See #9 and #10 in the General information section for additional guidance.

Precertification for all members with HMO- based, Aetna Medicare Advantage plans, and insured Aetna commercial when performed in any facility except inpatient, emergency room and observation bed status. • Providers 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

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. − 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 − Medical review – Coverage are valid for six months in all states. This determinations made for items on the is the case unless we tell you otherwise precertification list are utilization review when you receive the precertification decisions. We review plan document s decision. and (when applicable) clinical • Every year, in January and July, we information. This is how we determine typically update the precertification list. But whether the requested service, we m ay add new FDA-approved drugs to the procedure, prescription drug or medical list at different times. device meets the clinical guidelines/criteria • Visit Clinical Policy Bulletins and our for coverage. online provider directory. • We need to receive requests for • The precertification process doesn’t include precertification before you provide services. verbal or written requests for information − We encourage providers to submit about benefits or services not on the precertification requests at least two precertification lists. Our staff members are weeks before the scheduled educated to determine whether a caller is services. making an inquiry or requesting a coverage − To save you time0 it’s best to submit decision/organization determination as part precertification requests and inquiries of the intake process. electronically. This is the quickest way to • Find more about notification and coverage receive an authorization for services determinations. requiring precertification. If you need help, 2. We don’t offer all plans in all service areas, and not just call us. Look for the “precertification” all plans include all services listed. For example, number on the member’s ID card. precertification programs don’t apply to fully insured − If you don’t precertify the services on this members in Indiana. list, the member’s health plan (the “health 3. Innovation Health Insurance Company and Innovation plan”)0 employer group or member won’t Health Plan, Inc. (Innovation Health) are affiliates of be financially responsible for the Aetna Company (Aetna) and its affiliates. applicable service(s) if you provide those Aetna and its affiliates provide certain management services. services for Innovation Health. • This material is for your information only. It’s 4. Find more information about notification and not meant to direct treatment decisions. coverage determinations. • The review of items on this list may vary at

our discretion. If you receive approval for a 5. We require precertification when Aetna or Innovation particular service or supply, it’s for that service Health is the secondary payer. or supply only. • Services that don’t require precertification are subject to the coverage terms of the member’s plan.

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General information, continued 6. We require precertification for maternity and − Drug coverage continues for these newborn stays that are more than the standard members as long as the drug length of stay (LOS). Standard LOS for: is medically necessary and more medically • Vaginal deliveries is three days 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 medications not on this Colorado state contract0 we’ll approve or deny list. precertification requests within time frames mandated by • See #9 in General information section for 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 1-866-782-2779 for 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 or physical/occupational therapy 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 − Drug coverage continues for these • Hip and knee arthroplasties California members as long as the • Physical therapy and occupational therapy drug is appropriately prescribed • Pain management and considered safe and effective • Polysomnography treatment for the medical • Radiology imaging 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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