sign in sign up
<<
Home , Brolucizumab, Burosumab, Caplacizumab, Crizanlizumab, Evinacumab, Necitumumab

Last updated 9/7/2021

Services and Medicare Part B Drugs These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

HealthPartners Medicare products in scope unless noted otherwise: Journey plans (H4882), Robin plans (H4882), Freedom plans (H2462), Sanford plans (H2462), HealthPartners UnityPoint Health (H3416), MSHO (H2422)

Table of Contents • Services requiring prior authorization • Services no longer requiring prior authorization • Medicare Part B Drugs requiring prior authorization • Medicare Part B Drugs requiring step therapy • Medicare Drug Coverage Policies apply but does not require prior authorization

Services requiring prior authorization

1. Ambulance and medical transportation (fixed wing 19. Panniculectomy transport only) 20. Percutaneous tibial nerve stimulation (PTNS) for 2. Artificial intervertebral disc replacement – cervical overactive bladder 3. Artificial intervertebral disc replacement – lumbar 21. Pneumatic compression devices and heat/cold 4. Autologous chondrocyte implantation (ACI) therapy units 5. Automatic external defibrillator 22. Proton beam radiation therapy 6. growth stimulators, electrical and ultrasonic 23. Reconstructive surgery 7. Breast surgery 24. Repetitive transcranial magnetic stimulation 8. Chronic pain - multidisciplinary intensive day 25. Rhinoplasty and septorhinoplasty treatment programs 26. Sacroiliac (SI) joint fusion surgery 9. Cosmetic surgery/treatments 27. Sex therapy, sexual dysfunctions and paraphilic 10. Eye surgery – refractive disorders 11. Gender confirmation surgery 28. Spinal fusion, lumbar 12. Gynecomastia surgery 29. Transplants 13. Home hospice services 30. Upper airway/hypoglossal nerve stimulation therapy 14. In-network benefit requests for obstructive sleep apnea 15. Investigational services 31. Varicose vein procedures 16. Lift chair mechanism 32. Ventricular assist devices (VADs) and total artificial 17. Minimally invasive and laser spine procedures hearts 18. Nutritional support 33. Weight loss surgery

Services no longer requiring prior authorization

1. Category III CPT codes (retired 9/1/2021)

Medicare Part B Drugs (listed on the following medical policies) requiring prior authorization

1. Abatacept (Orencia®) iloprost (Ventavis®) and sildenafil injection 2. Ado- emtansine (Kadcyla®), fam- (Revatio®) -nxki (Enhertu®), 4. Afamelanotide (Scenesse®) (Perjeta®), trastuzumab (Herceptin®, 5. (Eylea®), -dbll (Beovu®), Herzuma®, Kanjinti™, Ogivri™, Ontruzant®, and (Lucentis®) Trazimera™), and trastuzumab and hyaluronidase- 6. Agalsidase beta (Fabrazyme®) oysk (Herceptin Hylecta™) 7. (Lemtrada™) 3. Advanced drug therapy for pulmonary hypertension: 8. Alpha-1 antitrypsin (AAT) deficiency enzyme epoprostenol (generic, Flolan® and Veletri®), replacement therapy: alpha-1 proteinase inhibitor treprostinil (generic, Remodulin® and Tyvaso®), (Aralast NP®, Glassia®, Prolastin®-C, and Zemaira®) 1

Last updated 9/7/2021

Services and Medicare Part B Drugs These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645. 9. (Benlysta®) 48. Luspatercept-aamt (Reblozyl®) 10. (Fasenra™) 49. for risk reduction of primary breast 11. (Avastin®, Mvasi™, Zirabev®) cancer in women 12. Bezlotoxumab (Zinplava™) 50. (Nucala®) 13. (Blincyto™) 51. -tdfk (Lumoxiti™) 14. factor products for hemophilia and other 52. Mucopolysaccharidoses (MPS) drug therapy clotting disorders 53. (Tysabri®) 15. Buprenophrine (Probuphine®) 54. (Portrazza®) 16. Buprenorphine injectable (Sublocade™) 55. (Spinraza®) 17. (Crysvita®) 56. (Ocrevus®) 18. (ILARIS®) 57. (Xolair®) 19. -yhdp (Cablivi®) 58. Onasemnogene abeparvovec-xioi (Zolgensma®) 20. Cerliponase alfa (Brineura®) 59. Oncology drug coverage 21. Certolizumab (Cimzia®) 60. Patisiran (Onpattro™) 22. Chimeric antigen receptor/genetically engineered T- 61. Peanut (arachis hypoqaea) allergen powder-dnfp cell receptor (CAR-T) therapy (Palforzia™) 23. Collagenase (Xiaflex®) 62. Pegloticase (Krystexxa®) 24. Compounded medications 63. Plerixafor (Mozobil®) 25. Crizanlizumab-tmca (Adakveo®) 64. Pompe disease enzyme replacement therapy: 26. Duopa® alglucosidase alfa (Lumizyme®) 27. (Soliris®) and -cwvz 65. Recent Food and Drug Administration (FDA) (Ultomiris™) approved medications coverage policy 28. Edavarone (Radicava®) 66. (Cinqair®) 29. Elapegademase-lvlr (Revcovi™) 67. (Rituxan®, Ruxience™, Truxima®, 30. -lzsg (Gamifant®) Rituxan Hycela®, and Riabni™) 31. -jjmr (Vyepti™) 68. -aqqg (Evenity®) 32. Esketamine (Spravato™) 69. -mwge (Enspryng ™) and - 33. (Exondys 51™) cdon (Uplizna ™) 34. -dgnb (Evkeeza™) 70. Sebelipase alfa (Kanuma®) 35. , , Tbo-Filgrastim and 71. Somatostatin analogues for acromegaly biosimilars (Sandostatin LAR®, Somatuline Depot®, Signifor 36. Fluocinolone acetonide implants (Retisert™) and LAR®, Somavert®) (Yutiq™) 72. Tagraxofusp-erzs (Elzonris™) 37. Fosdenopterin (Nulibry™) 73. -trbw (Tepezza®) 38. Givosiran (Givlaari®) 74. -asmn (Ilumya™) 39. (Simponi ARIA®) 75. (Actemra®) 40. (Vyondys 53®) 76. Type I Gaucher disease intravenous enzyme 41. (Tremfya®) replacement therapy: imiglucerase (Cerezyme®), 42. Hereditary angioedema (HAE) drug therapy velaglucerase (VPRIV®), and taliglucerase 43. -uiyk (Trogarzo™) (Elelyso®) 44. Immune globulin therapy 77. (Stelara®) 45. (Remicade®, Inflectra®, Renflexis®, 78. (Entyvio®) Avsola™) 79. Viltolarsen (Viltepso®) 46. (Yervoy®) 80. Voretigene neparvovec-rzyl (Luxturna™) 47. Lumasiran (Oxlumo™)

Medicare Part B Drugs requiring step therapy

None (subject to change at any time; would apply to new starts only)

2

Last updated 9/7/2021

Services and Medicare Part B Drugs These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

Medicare Drug Coverage Policies apply but does not require prior authorization

1. Abarelix (Plenaxis®) for the Treatment of Prostate 8. Intra-articular hyaluronan (Viscosupplementation) Cancer 9. Intravenous Iron Therapy 2. Anti-Inhibitor Coagulant Complex (AICC) 10. Levocarnitine for use in the Treatment of Carnitine 3. Bortezomib (Velcade®) Deficiency 4. Botulinum toxins: abobotulinumtoxinA (Dysport®), 11. Luteinizing Hormone-Releasing Hormone (LHRH) incobotulinumtoxinA (Xeomin®), onabotulinumtoxinA Analogs (Leuprolide, Goserelin, Triptorelin, Histrelin) (Botox®) and rimabotulinumtoxinB (Myobloc®) 12. Nesiritide (Natrecor®) for Treatment of Heart Failure 5. (Prolia®, Xgeva®) Patients 6. Erythropoiesis Agents in Cancer and Related 13. Paclitaxel (Taxol®/Abraxane™) Neoplastic Conditions 14. (Visudyne™) 7. Ibandronate Sodium (Boniva®) 15. Zoledronic Acid (Zometa®, Reclast®)

Please use this link to find coverage for medications on Medicare Part D: https://www.healthpartners.com/hp/insurance/medicare/prescription-drug-coverage/drug-list/index.html

3