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Home , Alemtuzumab, Eteplirsen, Golodirsen, Nusinersen, Onasemnogene abeparvovec, Ranibizumab

Last updated 10-01-2020

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 22. In-network benefit requests transport only) 23. Investigational services 2. Artificial intervertebral disc replacement – cervical 24. Lift chair mechanism 3. Artificial intervertebral disc replacement – lumbar 25. Minimally invasive and laser spine procedures 4. Autologous chondrocyte implantation (ACI) 26. Nutritional support 5. Automatic external defibrillator 27. Panniculectomy 6. stimulators, electronic and ultrasonic 28. Percutaneous tibial nerve stimulation (PTNS) for 7. Breast surgery overactive bladder 8. Category III CPT codes 29. Pneumatic compression devices and heat/cold 9. Chronic - multidisciplinary intensive day therapy units treatment programs 30. Prosthesis - upper limb 10. Cosmetic surgery/treatments 31. Proton beam radiation therapy 11. Deep brain stimulation and responsive 32. Reconstructive surgery neurostimulation for neurological movement 33. Repetitive transcranial magnetic stimulation disorders 34. Rhinoplasty and septorhinoplasty 12. Dental services - accidental dental 35. Sacroiliac (SI) joint fusion surgery 13. Dental services - ambulatory hospitalization and 36. Sex therapy, sexual dysfunctions and paraphilic anesthesia for dental care disorders 14. Dental services - cone beam computed tomography 37. Skilled nursing facility (SNF) (CBCT) scan for medically-related dental services 38. Spinal fusion, lumbar 15. Dental services - medically necessary outpatient 39. Temporomandibular disorder (TMD) 16. Dental services - orthognathic surgery 40. Transplants 17. Eye surgery – refractive 41. Varicose vein procedures 18. Gender reassignment surgery 42. Ventricular assist devices (VADs) and total artificial 19. Gynecomastia surgery hearts 20. Home hospice services 43. Weight loss surgery 21. In-home mental health psychotherapy services

Services no longer requiring prior authorization

1. Airway clearance system/ high frequency chest wall 7. Home health service (effective 11/1/2019) compression system (effective 6/1/2020) 8. Home phototherapy - full body cabinet (effective 2. Ankle replacement surgery (effective 11/1/2019) 8/1/2020) 3. Blepharoplasty, blepharoptosis repair, and brow lift 9. Hospital bed (effective 6/1/2020) (effective 8/1/2020) 10. Neuromuscular electrical stimulators (NMES) and 4. Breast pumps (effective 5/1/2020) functional electrical stimulators (FES) (effective 5. Cardiac event monitoring (effective 8/1/2020) 8/1/2020) 6. Cognitive rehabilitation (effective 6/1/2020) 1 Last updated 10-01-2020

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. 11. Oral appliances for sleep disorders (effective 17. Spine surgical practice - low office visits 11/1/2019) (effective 3/1/2020) 12. Pressure reducing support services (effective 18. Stereotactic radiosurgery and stereotactic body 6/1/2020) radiation therapy (effective 11/1/2019) 13. Primary hyperhidrosis treatments (effective 19. Uvulopalatopharyngoplasty (UPPP) for obstructive 11/1/2019) sleep apnea (OSA) (effective 11/1/2019) 14. Prosthesis - lower limb (effective 6/1/2020) 20. Wheelchairs - mobility assistive equipment (MAE) - 15. Reduction mammoplasty (effective 11/1/2019) (includes manual, power and scooter) (effective 16. Spinal cord and implanted peripheral nerve 8/1/2020) stimulation (effective 8/1/2020)

Medicare Part B Drugs requiring prior authorization

1. (Orencia®) 24. Duopa® 2. Ado- emtansine (Kadcyla®), fam- 25. (Soliris®) and ravulizumab-cwvz -nxki (Enhertu®), (Ultomiris™) (Perjeta®), trastuzumab (Herceptin®, 26. Edavarone (Radicava®) Herzuma®, Kanjinti™, Ogivri™, Ontruzant®, 27. Elapegademase-lvlr (Revcovi™) Trazimera™), and trastuzumab and hyaluronidase- 28. Emapalumab-lzsg (Gamifant®) oysk (Herceptin Hylecta™) 29. -jjmr (Vyepti™) 3. Advanced drug therapy for pulmonary hypertension: 30. Esketamine (Spravato™) epoprostenol (generic, Flolan® and Veletri®), 31. (Exondys 51™) treprostinil (generic, Remodulin® and Tyvaso®), 32. , , Tbo-Filgrastim and iloprost (Ventavis®) and sildenafil injection biosimilars (Revatio®) 33. Fluocinolone acetonide implants (Retisert™) and 4. (Eylea®), -dbll (Beovu®), (Yutiq™) and (Lucentis®) 34. Givosiran (Givlaari®) 5. Agalsidase beta (Fabrazyme®) 35. (Simponi ARIA®) 6. (Lemtrada™) 36. (Vyondys 53®) 7. Alpha-1 antitrypsin (AAT) deficiency 37. Guselkumab (Tremfya®) replacement therapy: alpha-1 proteinase inhibitor 38. Hereditary angioedema (HAE) drug therapy (Aralast NP®, Glassia®, Prolastin®-C, and 39. Ibalizumab-uiyk (Trogarzo™) Zemaira®) 40. Immune globulin therapy 8. (Benlysta®) 41. (Remicade®, Inflectra®, Renflexis®, 9. Benralizumab (Fasenra™) Avsola™) (Yervoy®) 10. (Avastin®, Mvasi™, Zirabev®) 42. Luspatercept-aamt (Reblozyl®) 11. Bezlotoxumab (Zinplava™) 43. for risk reduction of primary breast 12. (Blincyto™) cancer in women 13. Blood factor products for hemophilia and other 44. (Nucala®) clotting disorders 45. -tdfk (Lumoxiti™) 14. Buprenophrine (Probuphine®) 46. Mucopolysaccharidoses (MPS) drug therapy 15. Buprenorphine injectable (Sublocade™) 47. (Tysabri®) 16. (Crysvita®) 48. (Portrazza®) 17. Canakinumab (ILARIS®) 49. (Spinraza®) 18. -yhdp (Cablivi®) 50. (Ocrevus®) 19. Cerliponase alfa (Brineura®) 51. (Xolair®) 20. Certolizumab (Cimzia®) 52. -xioi (Zolgensma®) 21. Collagenase (Xiaflex®) 53. Oncology drug coverage 22. Compounded medications 54. Patisiran (Onpattro™) 23. Crizanlizumab-tmca (Adakveo®)

2 Last updated 10-01-2020

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. 55. Peanut (arachis hypoqaea) allergen powder-dnfp 64. Somatostatin analogues for acromegaly (Palforzia™) (Sandostatin LAR®, Somatuline Depot®, Signifor 56. Pegloticase (Krystexxa®) LAR®, Somavert®) 57. Plerixafor (Mozobil®) 65. Tagraxofusp-erzs (Elzonris™) 58. Pompe disease enzyme replacement therapy: 66. -trbw (Tepezza®) alglucosidase alfa (Lumizyme®) 67. Tildrakizumab-asmn (Ilumya™) 59. Recent Food and Drug Administration (FDA) 68. (Actemra®) approved medications coverage policy 69. Type I Gaucher disease intravenous enzyme 60. (Cinqair®) replacement therapy: imiglucerase (Cerezyme®), 61. (Rituxan®, Ruxience™, Truxima®, and velaglucerase (VPRIV®), and taliglucerase Rituxan Hycela®) (Elelyso®) 62. -aqqg (Evenity®) 70. (Stelara®) 63. Sebelipase alfa (Kanuma®) 71. (Entyvio®) 72. 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 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

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