Procedures, programs, and that require precertification

Participating provider precertification list

Starting October 1, 2021

Applies to: 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 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)

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83.03.829.1 J (10/21)

Services that require precertification: Do I need a referral before I get care? 1. Inpatient stays (except hospice) For benefit plans with a primary care For example, surgical and nonsurgical stays, stays in physician (PCP), you may need a referral for a skilled nursing facility or rehabilitation facility, and specialist care. In such a case, your PCP must maternity and newborn stays that exceed the refer you to a specialist. Please check the standard length of stay (LOS) back of your member ID card for your plan 2. Ambulance referral rules. Precertification required for transportation Do I needpreapproval beforeI get care? by fixed- wing aircraft (plane) 3. Arthroscopic hip surgery to repair impingement • In-network provider care syndrome including labral repair Beforeyou go for care to any participating 4. Autologous chondrocyte implantation provider, check with your doctor to be sure that 5. Cataract surgery - precertification required all needed prior approvals are in place. A effective 7/1/2021 participating provider can be any provider of 6. Chiari malformation decompression surgery health care and includes a specialist or facility. 7. Cochlear device and/or implantation Your networkprovider may need to get prior 8. Coverage at an in-network benefit level for out­ approval for additional care as partof an Aetna of­ network provider or facility unless services are special program. This includes services like emergent. Some plans have limited or no out of network benefits. transplants and certain women’s health 9. Dental implants services (infertility, BRCA or pre-implantation 10. Dialysis visits genetic testing). Also, When request is initiated by a participating provider, precertification may apply for local programs and dialysis to be performed at a nonparticipating for services such as: facility • Cardiac catheterizations and rhythm implants 11. Dorsal column (lumbar) neurostimulators: • Hip and knee replacements trial or implantation • management 12. Electric or motorized wheelchairs and scooters 13. Endoscopic nasal balloon dilation procedures • Radiology/imaging services 14. Functionalendoscopic sinussurgery(FESS) • Sleep studies 15. Gender affirmation surgery The network provider gets prior approval, if needed. 16. Hyperbaric oxygen You don’t have to pay if the provider fails to get prior 17. Lower limb prosthetics, such as approval. microprocessor- controlled lower limb • Out-of-network provider care prosthetics You may need approval to see out-of­ 18. Nonparticipating freestanding ambulatory network providers. Be sure to check your plan surgical facility services, when referred by documents about prior approval rules. You a participating provider

must get prior approval, if needed. Your plan 19. Orthognathic surgery procedures, grafts, osteotomies and surgical management of the benefits may be less or not covered if you temporomandibular joint don’t get prior approval. That means you 20. Osseointegrated implant must pay for these charges. 21. Osteochondral allograft/knee • Pharmacy 22. Private duty nursing You might have different benefits for 23. Proton beam radiotherapy drugs covered under a pharmacy plan. 24. Reconstructive or other procedures that These drugs may also have different maybe considered cosmetic, such as: prior approval requirements. • Blepharoplasty/ canthoplasty More questions? • Breast reconstruction/ breast enlargement Look at your member booklet to find out what • Breast reduction/ mammoplast y your medical plan covers. Or log in to your • Excision of excessive skin due to weight loss secure member website. You can also call us at • Gastroplasty/gastric bypass the toll- free number on your member ID card. • Lipectomy or excessfat removal • Surgery for varicose veins, except stab phlebectomy 25. Shoulder arthroplasty including revision procedures

Proprietary

26. Spinal procedures, such as: 27. Uvulopalatopharyngoplasty, including laser • Artificial intervertebral disc surgery (cervical assisted procedures spine) 28. Ventricular assist devices • Arthrodesis for spine deformity 29. Video electroencephalograph (EEG) • Cervical laminoplasty 30. Whole exome sequencing • Cervical, lumbar and thoracic laminectomy and\or laminotomy procedures • Kyphectomy • Laminectomy with rhizotomy • Spinal fusion surgery – precertificationrequired for sacroiliac joint fusionsurgeryeffective 7/1/2021 • Vertebral corpectomy – precertification required effective 7/1/2021

Proprietary

Drugs and medical injectables

Blood- clotting factors (precertification for outpatient infusion of this classis required)

For the following services, providers should call 1-855-888-9046 for precertification with the following exceptions: • For MHBP, please call CVS/Caremarkat1-800-237-2767 • For the Foreign Service Benefit Plan, please call Express Scripts at 1-800-922-8279 • For the Rural Carrier Benefit Plan, please call CVS Caremark® at 1-800-237-2767

Advate (antihemophilic factor, recombinant) Idelvion (antihemophilic factor [recombinant]) Adynovate (antihemophilic factor [recombinant], Ixinity (coagulation factor IX [recombinant]) PEGylated) Jivi [antihemophilic factor (recombinant), PEGylated­ Afstyla (antihemophilic factor [recombinant], single aucl] chain) Koate, Koate-DVI (antihemophilic factor [human]) Alphanate (antihemophilic factor/von Kogenate FS (antihemophilic factor [recombinant]) Willebrand factor complex [human]) Kovaltry (antihemophilic factor [recombinant]) AlphaNine SD (coagulation factor IX [human]) Monoclate-P (antihemophilic factor [human]) Alprolix (coagulation factor IX [recombinant], Fc Mononine (coagulation factor IX [human]) fusion protein) NovoEight (turoctocog alfa) Bebulin (factor IX complex) NovoSeven RT (coagulation factor VIIa BeneFix (coagulation factor IX [recombinant]) [recombinant]) Coagadex (coagulation factor X [human]) Nuwiq (simoctocog alfa) Corifact (factor XIII concentrate [human]) Obizur (antihemophilic factor [recombinant], Eloctate (antihemophilic factor [recombinant], Fc porcine sequence) fusion protein) Profilnine (factor IX complex) Esperoct [antihemophilic factor (recombinant), Rebinyn (coagulation factor IX [recombinant], glycopegylated-exei] glycoPEGylated) FEIBA, FEIBA NF (anti-inhibitor coagulant Recombinate (antihemophilic factor [recombinant]) complex) RiaSTAP (fibrinogen concentrate [human]) Fibryga (fibrinogen, human) Rixubis (coagulation factor IX [recombinant]) Helixate FS (antihemophilic factor Sevenfact (coagulation factor VIIa [recombinant]­ [recombinant]) jncw) Hemlibra (emicizumab-kxwh) Tretten (coagulation factor XIII a-subunit [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]) Xyntha, Xyntha Solof (antihemophilic factor [recombinant])

Proprietary

Other drugs and medical injectables For thefollowing services, providerscall1 -866-752-7021 or fax applicable request forms to 1-888-267-3277, with the following exceptions: • For precertification of pharmacy-covered specialty drugs (noted with*) when you are enrolled in a commercial plan, your provider will call 1-855-240-0535. Or, they can fax applicable request forms to 1-877-269-9916. • Your provider can use the drug-specific Specialty Request Form located online under “Specialty Pharmacy Precertification.” • Your provider can submit Specialty Pharmacy precertification requests electronically using provider online tools and resources at our provider portal with Aetna. • Please see our Medicare online resources for more information about preferred products or to find a precertification fax form. • When you’re enrolled in a Foreign Service BenefitPlan,MHBP or Rural Carrier BenefitPlan, ask your provider to 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

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

Proprietary

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

Immunoglobulins, cont. Injectable infertility drugs, cont. Hizentra (immune globulin) Follistim AQ (follitropin beta) HyQvia (immune globulin) Ganirelix AC (ganirelix acetate) Octagam (immune globulin) Gonal-f (follitropin alfa) Panzyga (immune globulin) Gonal-f RFF (follitropin alfa) Privigen (immune globulin) Menopur (menotropins) Xembify (immune globulin) Novarel (chorionic gonadotropin) Immunologic agents: Ovidrel (choriogonadotropin alfa) Avsola (infliximab-axxq) — precertification Pregnyl (chorionic gonadotropin) for the drug and site of care required Injectafer (ferric carboxymaltose injection) Actemra (tocilizumab) — precertification for Jelmyto (mitomycin) the drug and site of care required Khapzory (levoleucovorin) Actemra* SC (tocilizumab) Kyprolis (carfilzomib) — precertification required Cimzia* (certolizumab pegol) effective 9/1/2021 for multiple myeloma only Cosentyx* (secukinumab) Lartruvo (olaratumab) Enbrel* (etanercept) Luteinizing hormone-releasing hormone (LHRH) Enspryng* (satralizumab) agents: Entyvio (vedolizumab) — precertification for Camcevi (leuprolide mesylate) — precertification the drug and site of care required required effective 8/1/2021 Humira* (adalimumab) Eligard (leuprolide acetate) Ilumya* (tildrakizumab) Firmagon (degarelix) Inflectra (infliximab-dyyb) — precertification Lupron Depot (leuprolide acetate), 7.5 mg for the drug and site of care required Trelstar (triptorelin pamoate) Kevzara* (sarilumab) Zoladex (goserelin) Kineret* (anakinra) Lumoxiti (moxetumomab pasudotox-tdfk) Olumiant* (baricitinib) Makena (hydroxyprogesterone capoate) Orencia SQ* (abatacept) Monjuvi (tafasitamab-cxix) Orencia IV (abatacept) — precertification for Multiple sclerosis drugs: the drug and site of care required Aubagio* (teriflunomide) Otezla* (apremilast) Avonex* (interferon beta-1a) Remicade (infliximab) — precertification for Bafiertam* (monomethyl fumarate) the drug and site of care required Betaseron* (interferon beta-1b) Renflexis (infliximab-abda) — Copaxone* (glatiramer acetate) precertification for the drug and site of Extavia* (interferon beta-1b) care required Gilenya* (fingolimod hydrochloride) Riabni (rituximab-arrx) — precertification Glatopa* (glatiramer acetate injection) required effective 4/2/2021 Kesimpta* (ofatumumab) Rinvoq (upadacitinib) Lemtrada (alemtuzumab) — precertification Rituxan (rituximab) for the drug and site of care required Rituxan Hycela (rituximab/hyaluronidase Mavenclad* (cladribine) human) Mayzent* (siponimod) Ruxience (rituximab-pvvr) Ocrevus (ocrelizumab) — precertification for Siliq* (brodalumab) the drug and site of care required Simponi* (golimumab) Plegridy* (peginterferon beta-1a) Simponi Aria (golimumab) — precertification Ponvory* (ponesimod) — precertification for the drug and site of care required required effective 5/1/2021 Skyrizi* (risankizumab-rzaa) Rebif* (interferon beta-1a) Stelara* (ustekinumab) Tecfidera* (dimethyl fumarate) Stelara IV (ustekinumab) Tysabri (natalizumab) — precertification for the Taltz* (ixekizumab) drug and site of care required Tremfya* (guselkumab) Vumerity* (diroximel fumarate) Truxima (rituximab-abbs) Zeposia* (ozanimod) Xeljanz,* Xeljanz XR* (tofacitinib) Muscular dystrophy drugs: Injectable infertility drugs: Amondys 45 () — precertification for the chorionic gonadotropin drug and site of care required effective 6/1/2021 Bravelle (urofollitropin) Exondys 51 () — precertification for the Cetrotide (cetrorelix acetate) drug and site of care required Proprietary

Muscular dystrophy drugs, cont. Pulmonary arterial hypertension drugs, cont. Emflaza* (deflazacort) Opsumit* (macitentan) Viltepso () — precertification for the drug Orenitram* (treprostinil diolamine) and site of care required Remodulin (treprostinil sodium) Vyondys 53 () — precertification for the Revatio* (sildenafil citrate) drug and site of care required Tracleer* (bosentan) Mvasi (bevacizumab-awwb) — precertification Tyvaso (treprostinil) required for oncology indications only Uptravi* (selexipag) Myalept (metreleptin) Veletri (epoprostenol sodium) Natpara (parathyroid hormone) Ventavis (iloprost) Nulibry (fosdenopterin) — precertification required Reblozyl (luspatercept) effective 6/1/2021 Respiratory injectables (precertification required Onpattro (patisiran) — precertification for the drug and site of care required): and site of care required Cinqair (reslizumab) Ophthalmic injectables: Fasenra (benralizumab) Beovu (-dbll) Nucala (mepolizumab) Eylea (aflibercept) Xolair (omalizumab) Lucentis () Rybrevant (amivantamab-vmjw) — precertification Luxturna (voretigene neparvovec-rzyl) — required effective 8/6/2021 precertification for the drug and site of care Ryplazim (plasminogen, human-tvmh) — required precertification required effective 8/1/2021 Macugen (pegaptanib) Saphnelo (anifrolumab-fnia) — precertification for the Tepezza (teprotumumab-trbw) – precertification drug and site of care required effective 10/7/2021 for the drug and site of care required Sarclisa (isatuximab-irfc) Osteoporosis drugs: Soliris (eculizumab) — precertification for the Bonsity* (teriparatide) drug and site of care required Evenity* (-aqqg) Somatostatin agents: Forteo* (teriparatide) Bynfezia (octreotide) Miacalcin (calcitonin) Sandostatin (octreotide) Prolia () Sandostatin LAR (octreotide acetate) Tymlos* (abaloparatide) Signifor (pasireotide) Oxlumo (lumasiran) — precertification for Signifor LAR (pasireotide) drug and site of care required effective Somatuline (lanreotide) 3/17/2021 Somavert (pegvisomant) Padcev (enfortumab vedotin) Spinraza () — precertification Parsabiv (etelcalcetide) required and effective 7/1/2021 site of care PD1/PDL1 drugs (precertification for the drug required and site of care required): Spravato(esketamine) Bavencio (avelumab) Synagis (palivizumab) Imfinzi (durvalumab) Tegsedi (inotersen) Jemperli (dostarlimab-gxly) — precertification Treanda (bendamustine HCl) for the drug and site of care required Trodelvy (sacituzumab govitecan-hziy) effective 7/1/2021 Ultomiris (Ravulizumab-cwvz) — Keytruda (pembrolizumab) precertification for drug and site of care Libtayo (cemiplimab-rwlc) required Opdivo (nivolumab) Uplizna (inebilizumab-cdon) — precertification for Tecentriq (atezolizumab) the drug and site of care required Pepaxto (melphalan flufenamide) — precertification Vectibix (panitumumab) required effective 6/1/2021 Velcade (bortezomib) — precertification Polivy (polatuzumab vedotin-piiq) required effective 9/1/2021 for multiple Provenge (sipuleucel-T) myeloma only Pulmonary arterial hypertension drugs: Viscosupplementation: All epoprostenol sodium and sildenafil citrate* Durolane () Adcirca* (Alyq, tadalafil) Euflexxa, Hyalgan, Genvisc, Supartz FX, Adempas* (riociguat) TriVisc, Visco 3 (sodium hyaluronate) Flolan (epoprostenol sodium) Gel-One (cross-linked hyaluronate) Letairis* (ambrisentan) Gelsyn-3, Hymovis (hyaluronic acid) Proprietary

Viscosupplementation, cont. Zolgensma (­ Monovisc, Orthovisc (sodium hyaluronate) xioi) — precertification for drug and site of Synojoynt, Triluron(1% sodium hyaluronate) care required Synvisc, Synvisc-One (hylan) Zulresso (brexanolone) Xgeva (denosumab) Zynlonta (loncastuximab tesirine-lpyl) — Xofigo (radium Ra 223 dichloride) precertification required effective 7/1/2021 Yervoy (ipilimumab) — precertification for the drug and site of care required Zirabev (bevacizumab-bvzr) — precertification required for oncology indications only

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