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Home , Brolucizumab, Burosumab, Crizanlizumab, Eteplirsen, Golodirsen, Ranibizumab

Last updated 10/1/2021

Services and Medicare Part B 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 • Medicare 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 - 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. Ado- emtansine (Kadcyla®), fam- 3. Afamelanotide (Scenesse®) -nxki (Enhertu®), 4. (Eylea®), -dbll (Beovu®), (Perjeta®), trastuzumab (Herceptin®, and (Lucentis®) Herzuma®, Kanjinti™, Ogivri™, Ontruzant®, 5. Agalsidase beta (Fabrazyme®) Trazimera™), and trastuzumab and hyaluronidase- 6. Alemtuzumab (Lemtrada™) oysk (Herceptin Hylecta™) 7. Alpha-1 antitrypsin (AAT) deficiency 2. Advanced drug therapy for pulmonary hypertension: replacement therapy: alpha-1 proteinase inhibitor epoprostenol (generic, Flolan® and Veletri®), (Aralast NP®, Glassia®, Prolastin®-C, and treprostinil (generic, Remodulin® and Tyvaso®), Zemaira®) iloprost (Ventavis®) and sildenafil injection 8. (Benlysta®) (Revatio®) 9. (Avastin®, Mvasi™, Zirabev®) 1

Last updated 10/1/2021

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.

10. Bezlotoxumab (Zinplava™) 43. Luspatercept-aamt (Reblozyl®) 11. Blinatumomab (Blincyto™) 44. for risk reduction of primary breast 12. factor products for hemophilia and other cancer in women clotting disorders 45. Moxetumomab pasudotox-tdfk (Lumoxiti™) 13. Buprenophrine (Probuphine®) 46. Mucopolysaccharidoses (MPS) drug therapy 14. Buprenorphine injectable (Sublocade™) 47. (Portrazza®) 15. (Crysvita®) 48. (Spinraza®) 16. (ILARIS®) 49. -xioi (Zolgensma®) 17. -yhdp (Cablivi®) 50. Oncology drug coverage 18. Cerliponase alfa (Brineura®) 51. Patisiran (Onpattro™) 19. Certolizumab (Cimzia®) 52. Peanut (arachis hypoqaea) allergen powder-dnfp 20. Chimeric receptor/genetically engineered T- (Palforzia™) cell receptor (CAR-T) therapy 53. (Neulasta®, Fulphila™, Nyvepria™, 21. Compounded medications Udenyca™, and Ziextenzo®) 22. Crizanlizumab-tmca (Adakveo®) 54. Pegloticase (Krystexxa®) 23. Duopa® 55. Plerixafor (Mozobil®) 24. (Soliris®) and -cwvz 56. Pompe disease enzyme replacement therapy: (Ultomiris™) alglucosidase alfa (Lumizyme®) 25. Edavarone (Radicava®) 57. Recent Food and Drug Administration (FDA) 26. Elapegademase-lvlr (Revcovi™) approved medications coverage policy 27. -lzsg (Gamifant®) 58. Rituximab (Rituxan®, Ruxience™, Truxima®, 28. -jjmr (Vyepti™) Rituxan Hycela®, and Riabni™) 29. Esketamine (Spravato™) 59. -mwge (Enspryng ™) and - 30. (Exondys 51™) cdon (Uplizna ™) 31. -dgnb (Evkeeza™) 60. Sebelipase alfa (Kanuma®) 32. Fluocinolone acetonide implants (Retisert™) and 61. Somatostatin analogues for acromegaly (Yutiq™) (Sandostatin LAR®, Somatuline Depot®, Signifor 33. Fosdenopterin (Nulibry™) LAR®, Somavert®) 34. Givosiran (Givlaari®) 62. Tagraxofusp-erzs (Elzonris™) 35. (Vyondys 53®) 63. -trbw (Tepezza®) 36. (Tremfya®) 64. -asmn (Ilumya™) 37. Hereditary angioedema (HAE) drug therapy 65. Type I Gaucher disease intravenous enzyme 38. -uiyk (Trogarzo™) replacement therapy: imiglucerase (Cerezyme®), 39. Immune globulin therapy velaglucerase (VPRIV®), and taliglucerase 40. (Remicade®, Inflectra®, Renflexis®, (Elelyso®) Avsola™) 66. (Stelara®) 41. (Yervoy®) 67. (Viltepso®) 42. Lumasiran (Oxlumo™) 68. Voretigene neparvovec-rzyl (Luxturna™)

Medicare Part B Drugs requiring step therapy

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

Medicare Drug Coverage Policies apply but does not require prior authorization

1. Abarelix (Plenaxis®) for the Treatment of Prostate 4. (Fasenra™) Cancer 5. Bortezomib (Velcade®) 2. Abatacept (Orencia®) 6. Botulinum toxins: abobotulinumtoxinA (Dysport®), 3. Anti-Inhibitor Coagulant Complex (AICC) incobotulinumtoxinA (Xeomin®), onabotulinumtoxinA (Botox®) and rimabotulinumtoxinB (Myobloc®) 2

Last updated 10/1/2021

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.

7. Collagenase (Xiaflex®) 16. (Nucala®) 8. (Prolia®, Xgeva®) 17. (Tysabri®) 9. Erythropoiesis Agents in Cancer and Related 18. Nesiritide (Natrecor®) for Treatment of Heart Failure Neoplastic Conditions Patients 10. (Simponi ARIA®) 19. (Ocrevus®) 11. Ibandronate Sodium (Boniva®) 20. (Xolair®) 12. Intra-articular hyaluronan (Viscosupplementation) 21. Paclitaxel (Taxol®/Abraxane™) 13. Intravenous Iron Therapy 22. (Cinqair®) 14. Levocarnitine for use in the Treatment of Carnitine 23. -aqqg (Evenity®) Deficiency 24. (Actemra®) 15. Luteinizing Hormone-Releasing Hormone (LHRH) 25. (Entyvio®) Analogs (Leuprolide, Goserelin, Triptorelin, Histrelin) 26. (Visudyne™) 27. (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

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