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NOTICE - Kent County Levy Court plan designs may not cover all items listed below. Call Aetna to inquire. Procedures, programs and drugs you must precertify

Participating provider precertification list

Effective July 1, 2018

Applies to1,2,3,4,9: 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 9 Foreign Ser vice 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

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.

23.03.882.1 P (7/18) For additional information, read all 12. Gender reassignment surgery 24. Reconstructive or other procedures general precertification information. 13. Hip surgery to repair impingement that may be considered cosmetic, Most precertification requests can be syndrome such as: submitted electronically through the • Blepharoplasty/canthoplasty 14. Home health care related services• • Breast reconstruction/breast secured provider website or using your Precertification is required for Medicare Electronic Medical Record (EMR) system enlargement Advantage members (only) after the 60th portal. • Breast reduction/mammoplasty consecutive day of treatment for services such as: • Excision of excessive skin due to weight • Home dialysis 1. Inpatient confinements (except hospice) loss • Home health aide or certified nursing For example, surgical and nonsurgical stays; stays • Gastroplasty/gastric bypass assistant in a skilled nursing facility or rehabilitation facility; • Lipectomy or excess fat removal • Home infusion/injectable therapy and maternity and newborn stays that exceed the • Surgery for varicose veins, except stab 5 • Home nursing care by registered or standard length of stay (LOS) phlebectomy licensed nurse 2. Observation stays more than 24 hours – • Home physical/occupational, respiratory 25. Spinal procedures, such as: precertification isn’t required effective 7/1/2018 and/or speech therapy • Artificial inter vertebral disc surgery • (cervical spine) 3. Ambulance NOTE: Precertification for these services • Cervical, lumbar and thoracic Precertification required for transportation is no longer required effective 6/1/2018 laminectomy/laminotomy by fixed-wing aircraft (plane) 15. Hyperbaric oxygen therapy procedures 16. Lower limb prosthetics, such as: 4. Autologous chondrocyte implantation, • Spinal fusion surgery ® Microprocessor-controlled lower limb Carticel prosthetics 26. Uvulopalatopharyngoplasty, including 5. Cochlear device and/or implantation laser-assisted procedures 17. Nonparticipating freestanding ambulatory 6. Coverage at an in-network benefit level for surgical facility services, when referred by 27. Ventricular assist devices out-of-network provider or facility unless a participating provider 28. Video electroencephalograph (EEG) services are emergent. Some plans have limited or no out-of-network benefits. 18. Orthognathic surgery procedures, bone grafts, osteotomies and surgical 7. Dental implants management of the temporomandibular 9 8. Dialysis visits joint • When request is initiated by a participating 19. Osseointegrated implant provider, and dialysis to be performed at a nonparticipating facility 20. Osteochondral allograft/knee • Call 1-866-503-0857 or fax applicable request 21. Power morcellation with uterine forms to 1-888-267-3277 myomectomy, with hysterectomy or for removal of uterine fibroids – precertification 9. Dorsal column (lumbar) neurostimulators: isn’t required effective 7/1/2018 trial or implantation 22. Private duty nursing 10. Electric or motorized wheelchairs and scooters 23. Proton beam radiotherapy 11. Gastrointestinal (GI) tract imaging through capsule endoscopy

7,8 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: • For precertification of pharmacy-covered specialty drugs — For Foreign Service Benefit Plan, please call Express Scripts at 1-800-922-8279. For MHBP and Rural Carrier Benefit Plan, please call CVS/Caremark at 1-800-237-2767

Advate (antihemophilic factor, human recombinant) Fibryga (fibrinogen, human) Nuwiq (simoctocog alfa) Adynovate (antihemophilic factor [recombinant], Helixate FS (antihemophilic factor [recombinant]) Obizur (antihemophilic factor [recombinant], porcine PEGylated) Hemlibra (emicizumab-kxwh) — precertification sequence) required effective 3/9/2018 Afstyla (antihemophilic factor [recombinant], single Profilnine (factor IX complex) chain) Hemofil M (antihemophilic factor [human]) Rebinyn (coagulation factor IX [recombinant], Alphanate (antihemophilic factor/von Willebrand Humate-P (antihemophilic factor/von Willebrand glycoPEGylated) — precertification required effective factor complex [human]) factor complex [human]) 3/9/2018 AlphaNine SD (coagulation factor IX [human]) Idelvion (antihemophilic factor [recombinant]) Recombinate (antihemophilic factor [recombinant]) Alprolix (coagulation factor IX [recombinant], Fc fusion Ixinity (coagulation factor IX [recombinant]) RiaSTAP (fibrinogen concentrate [human]) ) Koate, Koate-DVI (antihemophilic factor [human]) Rixubis (coagulation factor IX [recombinant]) Bebulin, Bebulin VH (factor IX complex) Kogenate FS (antihemophilic factor [recombinant]) Tretten (coagulation factor XIII a-subunit BeneFix (coagulation factor IX [recombinant]) Kovaltry (antihemophilic factor [recombinant]) [recombinant]) Coagadex (coagulation factor X [human]) Monoclate-P (antihemophilic factor [human]) Vonvendi (von Willebrand factor [recombinant]) Corifact (factor XIII concentrate [human]) Mononine (coagulation factor IX [human]) Wilate (von Willebrand factor/coagulation factor VIII complex [human]) Eloctate (antihemophilic factor [recombinant], Fc NovoEight (turoctocog alfa) Xyntha, Xyntha Solof (antihemophilic factor fusion protein) NovoSeven RT (coagulation factor VIIa [recombinant]) [recombinant]) FEIBA, FEIBA NF (anti-inhibitor coagulant complex) Other drugs and medical injectables: For the following services, providers call 1-866-503-0857 or fax applicable request forms to 1-888-267-3277, with the following exceptions: • For precertification of pharmacy-covered specialty drugs (noted with*) when 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 electronically using provider online tools and resources at NaviNet® drug precertification or CoverMyMeds with Aetna • For members enrolled in a Foreign Service Benefit Plan, MHBP or Rural Carrier Benefit Plan, providers use these contacts: - For precertification of pharmacy-covered specialty drugs — Foreign Service Benefit Plan, call Express Scripts at 1-800-922-8279; 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; MHBP, call 1-800- 410 -7778; Rural Carrier Benefit Plan, call 1-800 -638-8432

Acthar Gel/H. P. Acthar (corticotropin) Cardiovascular — PCSK9 Myozyme () Nutropin AQ* (somatropin) Actimmune (interferon gamma-1b) inhibitors: Naglazyme (galsulfase) Omnitrope* (somatropin) Adcetris (brentuximab vedotin) Praluent (alirocumab) Strensiq (asfotase alfa) Saizen* (somatropin) Alpha 1-proteinase inhibitor Repatha (evolocumab) Vimizim (elosulfase alfa) Serostim* (somatropin) (human): Chimeric Antigen Receptor T-Cell Zorbtive* (somatropin) VPRIV () Aralast NP (alpha 1-proteinase Therapy (CAR-T) — Contact Zomacton* (somatropin [rDNA origin]) Erbitux (cetuximab) inhibitor) National Medical Excellence at Hepatitis C drugs:

Glassia (alpha 1-proteinase inhibitor) 1-877-212-8811 Erythropoiesis-stimulating agents: Daklinza (daclatasvir) Prolastin-C (alpha 1-proteinase Kymriah (tisagenlecleucel) Aranesp (darbepoetin alfa) Epclusa (sofosbuvir and velpatasvir) inhibitor) Yescarta (axicabtagene ciloleucel) Epogen (epoetin alfa) Harvoni (sofosbuvir/ledipasvir) Zemaira (alpha 1-proteinase inhibitor) Crysvita (burosumab-twza) – Mircera (epoetin beta) Mavyret (glecaprevir/pibrentasvir) Amyotrophic Lateral Sclerosis (ALS) precertification for the drug and Procrit (epoetin alfa) Olysio (simeprevir) drugs: site of care required effective Fusilev (levoleucovorin) Sovaldi (sofosbuvir) Radicava (edaravone) — review of drug 7/13/2018 Gattex () Technivie (ombitasvir/paritaprevir/ and site of care required Cyramza (ramucirumab) Gazyva (obinutuzumab) ritonavir) Antiemetics: Darzalex (daratumumab) Granulocyte-colony stimulating Viekira Pak (paritaprevir/ritonavir/ Emend IV (fosaprepitant dimeglumine) ­ Dupixent* (dupilumab) factors: ombitasvir/dasabuvir) precertification for this drug and drug Empliciti (elotuzumab) Granix (injection tbo-filgrastim) Viekira XR (ombitasvir/paritaprevir/ class isn’t required effective 7/1/2018 replacement drugs: Leukine (injection sargramostim, ritonavir and dasabuvir) Benlysta (belimumab) Aldurazyme (laronidase) GM-CSF) Vosevi (sofosbuvir/velpatasvir/ Besponsa (inotuzumab ozogamicin) Brineura (cerliponase alfa) Neulasta (injection pegfilgrastim) voxilaprevir) Botulinum toxins: Cerezyme () Neupogen (injection filgrastim, G-CSF) Zepatier (elbasvir/grazoprevir) Botox (onabotulinumtoxinA) Elaprase () Zarxio (injection filgrastim, G- CSF, Hereditary angioedema agents: Dysport (abobotulinumtoxinA) Elelyso () biosimilar) Berinert (C1 esterase inhibitor) Myobloc (rimabotulinumtoxinB) Fabrazyme (agalsidase beta) Growth hormone: Cinryze (C1 esterase inhibitor) Xeomin (incobotulinumtoxinA) Kanuma () Genotropin* (somatropin) Firazyr (icatibant acetate) Calcitonin -Related Lumizyme (alglucosidase alfa) Humatrope* (somatropin) Haegarda (C1 esterase inhibitor (CGRP) receptor inhibitors – Mepsevii (vestronidase alfa-vjbk) — Increlex* (mecasermin) subcutaneous [human]) precertification for this drug class is precertification required effective Norditropin* (somatropin) Kalbitor (ecallantide) required effective 7/1/2018 2/9/2018 Ruconest (C1 esterase inhibitor)

Other drugs and medical injectables: HER 2 receptor drugs: Herceptin (trastuzumab) Rituxan (rituximab) Tysabri (natalizumab) — review of Veletri (epoprostenol sodium) Kadcyla (ado-trastuzumab emtansine) Simponi* (golimumab) drug and site of care required Ventavis (iloprost) Perjeta (pertuzumab) Simponi Aria (golimumab) Zinbryta* (daclizumab) Respiratory injectables: Ilaris* (canakinumab) Stelara* (ustekinumab) Muscular dystrophy drugs: Cinqair (reslizumab) Imlygic (talimogene laherparepvec) Stelara IV (ustekinumab) Exondys 51 () — review Fasenra (benralizumab) — Immunoglobulins (review of drug and Siliq* (brodalumab) of drug and site of care required precertification required effective site of care required): Taltz* (ixekizumab) Emflaza* (deflazacort) 2/9/2018 Bivigam (immune globulin) Tremfya* (guselkumab) Myalept () Nucala (mepolizumab) Carimune NF (immune globulin) Xeljanz,* Natpara (parathyroid hormone) Xolair (omalizumab) Cuvitru (immune globulin sc [human]) Xeljanz XR* (tofacitinib) Ophthalmic injectables: Soliris (eculizumab) — review of Flebogamma (immune globulin) Injectable infertility drugs: Eylea (aflibercept) drug and site of care required GamaSTAN S/D (immune globulin) All chorionic gonadotropin Lucentis (ranibizumab) Gammagard, Gammagard S/D Bravelle (urofollitropin) Luxturna (voretigene neparvovec-rzyl) Spinraza () Synagis (palivizumab) (immune globulin) Cetrotide (cetrorelix acetate) — precertification of drug and site Gammaked (immune globulin) Follistim AQ (follitropin beta) of care required effective 3/9/2018 Temodar oral formulation Gammaplex (immune globulin) Ganirelix AC (ganirelix acetate) Macugen (pegaptanib) (temozolomide) Gamunex-C (immune globulin) Gonal-f (follitropin alfa) Osteoporosis drugs: Vectibix (panitumumab) Hizentra (immune globulin) Gonal-f RFF (follitropin alfa) Forteo* (teriparatide) Viscosupplementation: HyQvia (immune globulin) Menopur (menotropins) Miacalcin (calcitonin) Durolane () – Octagam (immune globulin) Novarel (chorionic gonadotropin) Prolia (denosumab) precertification required effective Privigen (immune globulin) Ovidrel (choriogonadotropin alfa) Tymlos* (abaloparatide) 2/2/2018 Immunologic agents: Pregnyl (chorionic gonadotropin) PD1/PDL1 drugs: Euflexxa, Hyalgan, Genvisc, Supartz, Visco 3 (sodium hyaluronate) Actemra* (tocilizumab) Repronex (menotropins) Bavencio (avelumab) Gel-One (cross-linked hyaluronate) Actemra SC* (tocilizumab) Krystexxa (pegloticase) Imfinzi (durvalumab) Cimzia* (certolizumab pegol) Lartruvo (olaratumab) Keytruda (pembrolizumab) Gelsyn-3, Hymovis (hyaluronic acid) Cosentyx* (secukinumab) Makena (hydroxyprogesterone Opdivo (nivolumab) Monovisc, Orthovisc (sodium Enbrel* (etanercept) caproate) Tecentriq (atezolizumab) hyaluronate) Entyvio (vedolizumab) Multiple sclerosis drugs: Provenge (sipuleucel-T) Synvisc, Synvisc-One (hylan) Humira* (adalimumab) Aubagio* (teriflunomide) Pulmonary arterial hypertension Xeloda (capecitabine) Ilumya* (tildrakizumab) - Avonex* (interferon beta-1a) drugs: Xgeva (denosumab) precertification required effective Betaseron* (interferon beta-1b) All epoprostenol sodium and Xofigo (radium Ra 223 dichloride) 5/1/2018 Copaxone* (glatiramer acetate) sildenafil citrate* Yervoy (ipilimumab) Inflectra (infliximab-dyyb) — review of Extavia* (interferon beta-1b) Adcirca* (tadalafil) Zaltrap (ziv-aflibercept) drug and site of care required Gilenya* (fingolimod hydrochloride) Adempas* (riociguat) Kevzara* (sarilumab) Glatopa* (glatiramer acetate Flolan (epoprostenol sodium) Kineret* (anakinra) injection) Letairis* (ambrisentan) Orencia* (abatacept) Lemtrada (alemtuzumab) — review Opsumit* (macitentan) Otezla* (apremilast) of drug and site of care required Orenitram* (treprostinil diolamine) Remicade (infliximab) — review of Ocrevus (ocrelizumab) — review of Remodulin (treprostinil sodium) drug and site of care required drug and site of care required Revatio* (sildenafil citrate) Renflexis (infliximab-abda) — Plegridy* (peginterferon beta-1a) Tracleer* (bosentan) review of drug and site of care Rebif* (interferon beta-1a) Tyvaso (treprostinil) required Tecfidera* (dimethyl fumarate) Uptravi* (selexipag) Special programs

9 9 BRCA genetic testing — 1-877-794 -8720 - NJ through Triad Healthcare New Jersey IPA, Inc. Hip and knee arthroplasties Through our expanded national provider network: DBA eviCore healthcare New Jersey IPA Precertification for all members with plans Quest 1-866 -436 -3463 1-800 -409-9081 applicable to this precertification list unless Ambry 1-866 -262-7943 • For all members (with commercial and Aetna services are emergent: Baylor Miraca Genetics Laboratories, LLC — Medicare Advantage plans applicable to this • Providers in all states where applicable, except 1-800 -411-GENE or 713-798-6555 precertification list): metro and upstate New York and northern New BioReference, GeneDX, Genpath 1-888-729-1206 - GA through American Specialty Health (ASH) Jersey, should contact MedSolutions DBA eviCore Counsyl 1-888-268-6795 1-800-972-4226 healthcare to request preauthorization. You can reach MedSolutions DBA eviCore healthcare: Dynacare Northwest, Inc. 1-800-533-0567 (only • For all members (enrolled in commercial, Aetna for members who live in Washington or West Medicare Advantage and international plans - Online at evicore.com Virginia) applicable to this precertification list) when the - By phone at 1-888-693-3211 between 7 a.m. Invitae 1-800 - 436-3037 provider is contracted with OptumHealth/Aetna: and 8 p.m. ET LabCorp (for members living in the states of VA ,KS, - NC and SC through OptumHealth - By fax at 1- 84 4 -822-3862, Monday through MO, NE, UT and NC only) — 1-855-488-8750 1-800-34 4 -4584 Friday during normal business hours, or as Medical Diagnostic Laboratories 1-877-269- 0090 required by federal or state regulations Myriad Genetics 1-800- 469 -7423 Diagnostic Cardiology (cardiac rhythm 9 • Providers in metro and upstate New York and implantable devices, cardiac catheterization) Providers can use the BRCA form located online northern New Jersey should contact CareCore Precertification for all members with plans under the “Medical Precertification” section National DBA eviCore healthcare to request applicable to this precertification list unless to submit precertification requests. preauthorization. You can reach CareCore services are emergent: Find genetic counselors online — for a list of our National DBA eviCore healthcare: contracted providers, including our telephonic • Providers in all states where applicable, except - Online at evicore.com provider (InformedDNA), visit our provider metro and upstate New York and northern New directory. Jersey, should contact MedSolutions DBA eviCore - By phone at 1-888-622-7329 for metro and healthcare to request preauthorization. You can upstate New York or 1-888- 647-5940 for Chiropractic precertification9 reach MedSolutions DBA eviCore healthcare: northern New Jersey

• HMO-based plan members only - Online at evicore.com 9 Infertility program — 1-800-575-5999 - AZ through American Specialty Health (ASH) - By phone at 1-888-693-3211 between 7 a.m. 1-800 -972- 4226 and 8 p.m. ET Mental health or substance abuse services 9 • HMO-based plan and group Medicare members - By fax at 1- 84 4 -822-3862, Monday through precertification — See the member’s ID card Friday during normal business hours, or as ® only National Medical Excellence Program required by federal or state regulations - CA through American Specialty Health (ASH) By phone at 1-877-212-8811 for the following: • Providers in metro and upstate New York and 1-800-972-4226 northern New Jersey should contact CareCore • Kymriah (tisagenlecleucel) and Yescarta SM • HMO-based, Aetna Health Network Option , National DBA eviCore healthcare to request (axicabtagene ciloleucel) S M Aetna Health Network Only and Aetna Medicare preauthorization. You can reach CareCore • All major organ transplant evaluations and Advantage plan members only National DBA eviCore healthcare: transplants including, but not limited to, kidney, - Metro and upstate New York through American - Online at evicore.com liver, heart, lung and pancreas, and bone marrow Chiropractic Network (OptumHealth) - By phone at 1-888-622-7329 for metro and replacement or stem cell transfer after high-dose 1-888-329-5180 upstate New York or 1-888-647-5940 for northern chemotherapy New Jersey 9 9 Oncology pathway solutions (chemotherapy Pain management Polysomnography (attended sleep studies) 9 for cancer diagnosis) Precertification for all members with Precertification for all members with plans NOTE: Effective 7/1/2018, this program no longer plans applicable to this precertification list applicable to this precertification list when applies. unless services are emergent: performed in any facility except inpatient, emergency room and observation bed status The program applied to all Aetna Medicare • Providers in all states where applicable, except members, and the following members, who had a metro and upstate New York and northern New • Providers in all states where applicable, except cancer diagnosis and received chemotherapy Jersey, should contact MedSolutions DBA metro and upstate New York and northern New services in a physician’s office, outpatient hospital eviCore healthcare to request preauthorization. Jersey, should contactt MedSolutions DBA eviCore or ambulatory facility through 6/30/2018: You can reach MedSolutions DBA eviCore healthcare to request preauthorization. You can healthcare: reach MedSolutions DBA eviCore healthcare: • Members 18 or older in a commercial fully insured HMO/POS/PPO plan - Online at evicore.com - Online at evicore.com • Members 18 or older in a commercial self-insured - By phone at 1-888-693-3211 between 7 a.m. - By phone at 1-888-693-3211 between 7 a.m. HMO/POS/PPO plan when the plan sponsor had and 8 p.m. ET and 8 p.m. ET elected to participate in the program - By fax at 1- 84 4 -822-3862, Monday through - By fax at 1-844-822-3862, Monday through Providers in all states where applicable should Friday during normal business hours, or as Friday during normal business hours, or as required by federal or state regulations have contacted New Century Health: required by federal or state regulations • By phone at 1-877-624 -8601 (option 5), • Providers in metro and upstate New York and • Providers in metro and upstate New York and Monday – Friday, 8 a.m. – 8 p.m. ET northern New Jersey should contact CareCore northern New Jersey should contactt CareCore • By fax at 1-877-624 -8602 National DBA eviCore healthcare to request National DBA eviCore healthcare to request preauthorization. You can reach CareCore Outpatient physical therapy (PT) and preauthorization. You can reach CareCore 9 National DBA eviCore healthcare: occupational therapy (OT) precertification National DBA eviCore healthcare: - Online at evicore.com • Through OrthoNet 1-800-771-3205 - Online at evicore.com - By phone at 1-888-622-7329 for metro and - By phone at 1-888-622-7329 for metro and - CT — for all members with plans applicable to upstate New York or 1-888-647-5940 for upstate New York or 1-888- 647-5940 for this precertification list northern New Jersey northern New Jersey • Through OptumHealth 1-800-344-4584 (only Pediatric Congenital Heart Surgery Program — Pre-implantation genetic testing9 — OptumHealth/Aetna-contracted providers should See the member’s ID card to contact the 1-800 -575-5999 call this number for questions and service precertification unit 9 requests) Radiation oncology - DC, GA, NC, SC, VA — For all members with plans Precertification for all members with HMO-based applicable to this precertification list and Aetna Medicare Advantage plans only when performed in any facility except inpatient, - Program also applies to members in Chicago, emergencyy room and observation bed status northern IL and northwest IN (Lake and Porter counties) • Providers in metro and upstate New York and northern New Jersey should contactt 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 9 Radiology imaging Precertification for all members with plans applicable to this precertification list when performed in any facility except inpatient, emergencyy room and observation bed status • Providers in all states where applicable, except metro and upstate New York and northern New Jersey, should contactt MedSolutions DBA eviCore healthcare to request preauthorization. You can reach MedSolutions DBA eviCore healthcare: - Online at evicore.com - By phone at 1-888-693-3211 between 7 a.m. and 8 p.m. ET - By fax at 1- 84 4 -822-3862, Monday through Friday during normal business hours or as required by federal or state regulations • Providers in metro and upstate New York and northern New Jersey should contactt 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

Transthoracic echocardiogram9 Precertification for all members with plans applicable to this precertification list when performed in any facility except inpatient, emergency y room and observation bed status • Providers in metro and upstate New York and northern New Jersey should contact t 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

9 General information • Visit Clinical Policy Bulletins and our online provider directory.

1. We collect information before a member receives elective inpatient • The precertification process doesn’t include verbal or written requests for admissions and/or selected ambulatory procedures and services at the time information about benefits or services not on the precertification lists. Aetna of precertification. staff members are trained to determine whether a caller is making an inquiry or requesting a coverage decision/organization determination as part of the • We’ll enter decisions using one of the following processes as long as services intake process. are covered under the member’s plan: • Find more information about notification and coverage determinations. a. Notification is a data-entry process.It doesn’t require judgment or interpretation for benefits coverage. 2. We don’t offer all plans in all service areas, and not all plans include all services listed. For example, precertification programs don’t apply to fully b. Medical review; coverage determinations made for items on the precert insured members in Indiana. list are utilization review decisions. We review plan documents and (when applicable) clinical information. This is how we determine whether the 3. Innovation Health Insurance Company and Innovation Health Plan, Inc. requested service, procedure, or medical device meets (Innovation Health) are affiliates of Aetna Life Insurance Company (Aetna) and the clinical guidelines/criteria for coverage. its affiliates. Aetna and its affiliates provide certain management services for Innovation Health. • We need to receive requests for precertification before you provide services. • We encourage providers to submit precertification requests at least two 4. We require precertification when Aetna or Innovation Health is the secondary weeks before the scheduled services. payer. • We encourage providers to submit precertification requests electronically, this 5. We require precertification for maternity and newborn stays that are more is the quickest way to receive an authorization for services requiring precert. than the standard length of stay (LOS). Standard LOS for: • If you don’t precertify the services on this list, the member ’s health plan (the • Vaginal deliveries is three days or fewer “health plan”), employer groups or members won’t be financially responsible • Cesarean section is five days or fewer for the applicable service(s) if you still provide those services. • This material is for your information only. It’s not meant to direct treatment 6. All services described as “never effective” are excluded from coverage. Aetna decisions. defines a service as “never effective” when it’s not recognized according to professional standards of safety and effectiveness in the United States for • The review of items on this list may vary at our discretion. If you receive diagnosis, care or treatment. Visit aetna.com for more information. Select approval for a particular service or supply, it’s for that service or supply only. “Claims,” “CPT/HCPCS Coding Tool” and “Clinical Policy Code Lookup.” • To save you time, it’s best to submit precertification requests and inquiries online. If you need help, just call us. Look for the “precertification” number on 7. Contact Aetna Pharmacy Management for precertification of oral medications the member’s ID card. not on this list.9 Their number is 1-800 - 414 -2386. Call 1-866 -782-2779 for information on injectable medications not listed. • Services that don’t require precertification are subject to the coverage terms of the member’s plan. 8. For drugs administered orally, by injection or infusion: • For precertification in Texas, we use the utilization review process to • Drugs newly approved by the FDA may require precertification review. determine whether the requested service, procedure, prescription drug or medical device meets the company’s clinical criteria for coverage. • Fully insured Texas and Louisiana members continue to be covered for Precertification doesn’t mean payment for care or services to fully insured drugs added to the precertification list according to their current plan HMO and PPO members as defined by Texas law. design until their plan renewal date. • If member eligibility and plan coverage for the procedure/service you asked • Fully insured California HMO members and fully insured Connecticut PPO for hasn’t changed, precertification approvals are valid for six months in all members covered for drugs added to the precertification list continue to states. This is the case unless we tell you otherwise when you precertify. have coverage. • Every year, in January and July, we typically update the precertification list. - Drug coverage continues for these California members as long as the drug But we may add new U.S. Food and Drug Administration (FDA)-approved is appropriately prescribed and considered safe and effective treatment for drugs to the list at different times. the medical condition.

General information (continued) - 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. 9. For members enrolled in Foreign Service Benefit Plan, MHBP or Rural Carrier Benefit Plan: • Precertification is not required for cardiac catheterization, cardiac imaging, chiropractic services, transthoracic echocardiogram or physical/occupational therapy • Visit online provider directories: Foreign Service Benefit Plan; MHBP; Rural Carrier Benefit Plan • Except as noted for drugs and medical injectables and special programs, for all other services, Foreign Service Benefit Plan, call 1-800-593-2354; MHBP, call 1-800- 410 -7778; Rural Carrier Benefit Plan, call 1-800 -638-8432

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