Procedures, programs and drugs that require precertification

Proprietary

Procedures,

programs

and drugs that require

precertification

Participating provider precertification list

Starting May 1, 2020

Applies to the following plans

(also see General information section #1-#4, #9 -#10)

:

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)

aetna.com

23.03.882.1 G (5/20)

For additional information, read all general precertification information

Providers may submit most precertification requests electronically through the secure provider

website or

using your

Electronic Medical Record (EMR) system portal (See #1 in the General

Information section for more information on precertification).

Services that require precertification:

1.

Inpatient confinements (except hospice)

For example, surgical and nonsurgical stays,

stays in a skilled nursing facility or rehabilitation

facility, and maternity and newborn stays that

exceed the standard length of stay (LOS) (See #5

in the General Information section).

2.

Ambulance

Precertification required for transportation by

fixed- wing aircraft (plane)

3.

Autologous chondrocyte implantation

4.

Chiari malformation decompression surgery

5.

Cochlear device and/or implantation

6.

Coverage at an in-network benefit level

for out-of-network provider or facility

unless services are emergent.

Some plans have limited or no out-ofnetwork

benefits.

7.

Dental implants

8.

Dialysis visits

When a participating provider initiates a

request and dialysis is to be performed at a

nonparticipating facility, call 1-866-752-7021

for precertification. Or fax applicable request

forms to 1-888-267-3277.

9.

Dorsal column (lumbar)

neurostimulators: trial orimplantation

10.

Electric or motorized wheelchairs and

scooters

11.

Endoscopic nasal balloon dilation procedures

12.

Gender reassignment surgery

13.

Hip surgery to repair impingement syndrome

14.

Hyperbaric oxygen therapy

15.

Infertility services and pre-implantation

genetic testing

16.

Lower limb prosthetics, such as

microprocessor-controlled lower limb

prosthetics

17.

Nonparticipating freestanding

ambulatory surgical facility

services, when referred by a

participating provider

18.

Orthognathic surgery procedures,

bone grafts, osteotomies and surgical

management of the

temporomandibular joint

19.

Osseointegrated implant

20.

Osteochondral allograft/knee

21.

Private duty nursing

22.

Proton beam radiotherapy

Also see Special Programs; Radiation Oncology

23.

Reconstructive or other

procedures that maybe

considered cosmetic, suchas:

•

Blepharoplasty/canthoplasty

•

Breastreconstruction/breast enlargement

•

Breast reduction/mammoplasty

•

Excision of excessive skin due to weight loss

•

Gastroplasty/gastric bypass

•

Lipectomy or excess fat removal

•

Surgery for varicose veins,exceptstab phlebectomy

24.

Shoulder Arthroplasty

25.

Spinal procedures, such as:

•

Artificial intervertebral disc surgery (cervical spine)

•

Cervical laminoplasty

•

Cervical, lumbar and thoracic

laminectomy and\or laminotomy

procedures

•

Laminectomy with rhizotomy

•

Spinal fusionsurgery

26.

Uvulopalatopharyngoplasty,

including laser- assisted procedures

27.

Ventricular assist devices

28.

Video electroencephalograph (EEG)

29.

Whole exomesequencing

Proprietary

Drugs and medical injectables

Blood-clotting factors (precertification for outpatient infusion of this drug class is required)

Call t

he precertification number listed on the member’s card, with the following exceptions.

•

Precertification of pharmacy-covered specialty drugs

−

For the Foreign Service Benefit Plan, please call Express Scripts at 1-800-922-8279

−

For MHBP and the Rural Carrier Benefit Plan, please call CVS/Caremark at 1-800-237-2767

Advate (antihemophilic factor, human recombinant)

Adynovate (antihemophilic factor [recombinant],

PEGylated)

Afstyla (antihemophilic factor [recombinant],

single chain)

Alphanate (antihemophilic factor/von Willebrand

factor complex [human])

AlphaNine SD (coagulation factor IX [human])

Alprolix (coagulation factor IX [recombinant], Fc

fusion protein)

Bebulin (factor IX complex)

BeneFix (coagulation factor IX [recombinant])

Coagadex (coagulation factor X [human])

Corifact (factor XIII concentrate [human])

Eloctate (antihemophilic factor [recombinant], Fc

fusion protein)

Esperoct [antihemophilic factor (recombinant),

glycopegylated-exei] — precertification

required effective 4/1/2020

FEIBA, FEIBA NF (anti-inhibitor coagulant complex)

Fibryga (fibrinogen, human)

Helixate FS (antihemophilic factor [recombinant])

Hemlibra (emicizumab-kxwh)

Hemofil M (antihemophilic factor [human])

Humate-P (antihemophilic factor/von Willebrand

factor complex [human])

Idelvion (antihemophilic factor [recombinant])

Ixinity (coagulation factor IX [recombinant])

Jivi [antihemophilic factor (recombinant),

PEGylated-aucl]

Koate, Koate-DVI (antihemophilic factor [human])

Kogenate FS (antihemophilic factor [recombinant])

Kovaltry (antihemophilic factor [recombinant])

Monoclate-P (antihemophilic factor [human])

Mononine (coagulation factor IX [human])

NovoEight (turoctocog alfa)

NovoSeven RT (coagulation factor VIIa [recombinant])

Nuwiq (simoctocog alfa)

Obizur (antihemophilic factor [recombinant],

porcine sequence)

Profilnine (factor IX complex)

Rebinyn (coagulation factor IX [recombinant],

glycoPEGylated)

Recombinate (antihemophilic factor [recombinant])

RiaSTAP (fibrinogen concentrate [human])

Rixubis (coagulation factor IX [recombinant])

Tretten (coagulation factor XIII a-subunit

[recombinant])

Vonvendi (von Willebrand factor [recombinant])

Wilate (von Willebrand factor/coagulation factor

VIII complex [human])

Xyntha, Xyntha Solof (antihemophilic factor

[recombinant])

Proprietary

Other drugs and medical injectables

For the following services, providers call 1-866-752-7021 for precertification and fax applicable request

forms to 1-888-267-3277, with the following exceptions:

•

For precertification of pharmacy-covered specialty drugs (noted with *) when the 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 requests electronically using

provider online tools and resources at our provider portal with Aetna.

•

See our Medicare online resources for more information about preferred products or to find a precertification

fax form.

•

Providers should use the contacts below for members enrolled in a Foreign

Service Benefit Plan, MHBPor Rural Carrier BenefitPlan:

−

For precertification of pharmacy-covered specialty drugs — Foreign Service Benefit

Plan, call Express Scripts at 1-800-922-8279. For 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. For

MHBP, call 1-800-410-7778. For Rural Carrier Benefit Plan, call 1-800-638-8432.

Abraxane (paclitaxel) – precertification required for

Medicare Advantage members only

Acthar Gel/H. P. Acthar (corticotropin)

Adakveo (crizanlizumab-tmca) – precertification for

the drug and site of care required effective

2/13/2020

Adcetris (brentuximab vedotin)

Alpha 1-proteinase inhibitor (human)

(precertification for the drug and site of care

required):

Aralast NP (alpha 1-proteinase inhibitor)

Glassia (alpha 1-proteinase inhibitor)

Prolastin-C (alpha 1-proteinase inhibitor)

Zemaira (alpha 1- proteinase inhibitor)

Amyotrophic Lateral Sclerosis (ALS) drugs:

Radicava (edaravone) — precertification for the

drug and site of care required

Aveed (testosterone undecanoate)

Benlysta (belimumab) - precertification for the

drug and site of care required

Besponsa (inotuzumab ozogamicin)

Botulinum toxins:

Botox (onabotulinumtoxinA)

Dysport (abobotulinumtoxinA)

Myobloc (rimabotulinumtoxinB)

Xeomin (incobotulinumtoxinA)

Cablivi (caplacizumab-yhdp)

Calcitonin Gene-Related Peptide (CGRP) receptor

inhibitors

Vyepti (eptinezumab-jjmr) – precertification for

the drug and site of care required effective

5/28/2020

Cardiovascular — PCSK9 inhibitors:

Praluent* (alirocumab) Repatha*

(evolocumab)

Chimeric Antigen Receptor T-Cell Therapy (CAR-T)

— Contact National Medical Excellence at

1-877-212-8811

Kymriah (tisagenlecleucel)

Yescarta (axicabtagene ciloleucel)

Crysvita (burosumab) — precertification for

the drug and site of care required

Cyramza (ramucirumab)

Darzalex (daratumumab)

Dupixent* (dupilumab)

Empliciti (elotuzumab)

Enzyme replacement drugs:

Aldurazyme (laronidase) — precertification for the

drug and site of care required

Brineura (cerliponase alfa)

Cerezyme (imiglucerase) — precertification for the

drug and site of care required

.

Elaprase (idursulfase) — precertification

for the drug and site of care required

Elelyso (taliglucerase alfa) —

precertification for the drug and site of

care required

Fabrazyme (agalsidase beta) —

precertification for the drug and site of

care required

Kanuma (sebelipase alfa) —

precertification for the drug and site of

care required

Lumizyme (alglucosidase alfa) —precertification for

the drug and site of care required

Proprietary

Enzyme replacement drugs, cont.

Mepsevii (vestronidase alfa-vjbk) —precertification

for the drug and site of care required

Naglazyme (galsulfase) — precertification

for the drug and site of care required

Strensiq (asfotase alfa)

Vimizim (elosulfase alfa) — precertification

for the drug and site of care required

VPRIV (velaglucerase alfa) — precertification for

the drug and site of care required

Erbitux (cetuximab)

Erythropoiesis-stimulating agents:

Aranesp (darbepoetin alfa)

Epogen (epoetin alfa)

Mircera (epoetin beta)

Procrit (epoetin alfa)

Retacrit (recombinant human erythropoietin)

Fusilev (levoleucovorin)

Gattex (teduglutide)

Givlaari (givosiran) – precertification for drug and

site of care required effective 2/13/2020

Granulocyte-colony stimulating factors:

Fulphila (pegfilgrastim-jmdb)

Granix (tbo-filgrastim)

Leukine (sargramostim)

Neulasta (pegfilgrastim)

Neupogen (filgrastim)

Nivestym (filgrastim-aafi)

Udenyca (pegfilgrastim-cbvq)

Zarxio (filgrastim-sndz)

Ziextenzo (pegfilgrastim-bmez) – precertification

required effective 2/1/2020

Growth hormone:

Genotropin* (somatropin)

Humatrope* (somatropin)

Increlex* (mecasermin)

Norditropin*(somatropin)

Nutropin AQ* (somatropin)

Omnitrope* (somatropin)

Saizen* (somatropin)

Serostim* (somatropin)

Zomacton* (somatropin [rDNA origin])

Zorbtive* (somatropin)

Hepatitis C drugs

Daklinza* (daclatasvir)

Epclusa* (sofosbuvir and velpatasvir)

Harvoni* (sofosbuvir/ledipasvir)

Mavyret* (glecaprevir/pibrentasvir)

Olysio* (simeprevir)

Sovaldi* (sofosbuvir)

Technivie* (ombitasvir/paritaprevir/ritonavir)

Viekira Pak* (paritaprevir/ritonavir/

ombitasvir/dasabuvir)

Hepatitis C drugs, cont.

Viekira XR* (ombitasvir/paritaprevir/ritonavir and

dasabuvir)

Vosevi* (sofosbuvir/ velpatasvir/ voxilaprevir)

Zepatier* (elbasvir/grazoprevir)

Hereditary angioedema agents:

Berinert (C1 esterase inhibitor)

Cinryze (C1 esterase inhibitor) – precertification

for the drug and site of care required

Firazyr (icatibant acetate)

Haegarda (C1 esterase inhibitor subcutaneous

[human])

Kalbitor (ecallantide)

Ruconest (C1 esterase inhibitor)

Takhzyro (lanadelumab)

HER2 receptor drugs:

Enhertu (fam-trastuzumab deruxtecan-nxki) —

precertification required effective 3/24/2020

Herceptin (trastuzumab)

Herceptin Hylecta (trastuzumab and

hyaluronidase-oysk)

Kadcyla (ado-trastuzumab emtansine)

Kanjinti (trastuzumab-anns)

Ogivri (trastuzumab-dkst) — precertification

required effective 4/1/2020

Perjeta (pertuzumab)

Trazimera (trastuzumab-qyyp) — precertification

required effective 4/1/2020

Ilaris* (canakinumab)

Imlygic (talimogene laherparepvec)

Immunoglobulins (precertification for the drug and

site of care required):

Asceniv (immune globulin) — precertification

required effective 3/1/2020

Bivigam (immune globulin)

Carimune NF (immune globulin)

Cutaquig (immune globulin)

Cuvitru (immune globulin SC [human])

Flebogamma (immune globulin)

GamaSTAN S/D (immune globulin)

Gammagard, Gammagard S/D (immune globulin)

Gammaked (immune globulin)

Gammaplex (immune globulin)

Gamunex-C (immune globulin)

Hizentra (immune globulin)

HyQvia (immune globulin)

Octagam (immune globulin)

Panzyga (immune globulin)

Privigen (immune globulin)

Xembify (immune globulin)

Immunologic agents:

Actemra (tocilizumab) — precertification for the

drug and site of care required

Actemra* SC (tocilizumab)

Proprietary

Immunologic agents, cont.

Cimzia* (certolizumab pegol)

Cosentyx* (secukinumab)

Enbrel* (etanercept)

Entyvio (vedolizumab) — precertification for the

drug and site of care required

Humira* (adalimumab)

Ilumya* (tildrakizumab)

Inflectra (infliximab-dyyb) — precertification for

the drug and site of care required

Kevzara* (sarilumab)

Kineret* (anakinra)

Olumiant* (baricitinib)

Orencia SQ* (abatacept)

Orencia IV (abatacept) — precertification

for the drug and site of care required

Otezla* (apremilast)

Remicade (infliximab) — precertification

for the drug and site of care required

Renflexis (infliximab-abda) — precertification for

the drug and site of care required

Rinvoq (upadacitinib)

Rituxan (rituximab)

Ruxience (rituximab-pvvr) — precertification

required effective 4/1/2020

Siliq* (brodalumab)

Simponi* (golimumab)

Simponi Aria (golimumab) — precertification for

the drug and site of care required

Skyrizi* (risankizumab-rzaa)

Stelara* (ustekinumab)

Stelara IV (ustekinumab)

Taltz* (ixekizumab)

Tremfya* (guselkumab)

Truxima (rituximab-abbs)

Xeljanz*, Xeljanz XR* (tofacitinib)

Injectable infertility drugs:

chorionic gonadotropin

Bravelle (urofollitropin)

Cetrotide (cetrorelix acetate)

Follistim AQ (follitropin beta)

Ganirelix AC (ganirelix acetate)

Gonal-f (follitropin alfa)

Gonal-f RFF (follitropin alfa)

Menopur (menotropins)

Novarel (chorionic gonadotropin)

Ovidrel (choriogonadotropin alfa)

Pregnyl (chorionic gonadotropin)

Khapzory (levoleucovorin)

Lartruvo (olaratumab)

Lumoxiti (moxetumomab pasudotox-tdfk)

Makena (hydroxyprogesterone caproate)

Multiple sclerosis drugs

Aubagio* (teriflunomide)

Avonex* (interferon beta-1a)

Betaseron* (interferon beta-1b)

Copaxone* (glatiramer acetate)

Extavia* (interferon beta-1b)

Gilenya* (fingolimod hydrochloride)

Glatopa* (glatiramer acetate injection)

Lemtrada (alemtuzumab) — precertification for

the drug and site of care required

Mavenclad* (cladribine)

Mayzent* (siponimod)

Ocrevus (ocrelizumab) — precertification for the

drug and site of care required

Plegridy* (peginterferon beta-1a)

Rebif* (interferon beta-1a)

Tecfidera* (dimethyl fumarate)

Tysabri (natalizumab) — precertification for

the

drug and site of care required

Vumerity* (diroximel fumarate) – precertification

required effective 4/1/2020

Muscular dystrophy drugs:

Exondys 51 (eteplirsen) — precertification for the

drug and site of care required

Emflaza* (deflazacort)

Vyondys 53 (golodirsen) – precertification for

the drug and site of care required effective

3/10/2020

Myalept (metreleptin)

Natpara (parathyroid hormone)

Onpattro (patisiran) — precertification for the

drug and site of care required

Ophthalmic injectables:

Beovu (brolucizumab-dbll)

Eylea (aflibercept)

Lucentis (ranibizumab)

Luxturna (voretigene neparvovec-rzyl) —

precertification for the drug and site of care

required

Macugen (pegaptanib)

Tepezza (teprotumumab-trbw) – precertification

for the drug and site of care required

effective 5/1/2020

Osteoporosis drugs:

Bonsity* (teriparatide) – precertification

required effective 5/1/2020

Evenity* (romosozumab-aqqg)

Forteo* (teriparatide)

Miacalcin (calcitonin)

Prolia (denosumab)

Tymlos* (abaloparatide)

Padcev (enfortumab vedotin) — precertification

required effective 3/24/2020

Proprietary

Parsabiv (etelcalcetide)

PD1/PDL1 drugs

Bavencio (avelumab)

Imfinzi (durvalumab)

Keytruda (pembrolizumab)

Libtayo (cemiplimab-rwlc)

Opdivo (nivolumab)

Tecentriq (atezolizumab)

Polivy (polatuzumab vedotin-piiq)

Provenge (sipuleucel-T)

Pulmonary arterial hypertension drugs:

All epoprostenol sodium and sildenafil citrate*

Adcirca* (tadalafil)

Adempas* (riociguat)

Flolan (epoprostenol sodium)

Letairis* (ambrisentan)

Opsumit* (macitentan)

Orenitram* (treprostinil diolamine)

Remodulin (treprostinil sodium)

Revatio* (sildenafil citrate)

Tracleer* (bosentan)

Tyvaso (treprostinil)

Uptravi* (selexipag)

Veletri (epoprostenol sodium)

Ventavis (iloprost)

Reblozyl (luspatercept) – precertification

required effective 2/13/2020

Respiratory injectables:

Cinqair (reslizumab)

Fasenra (benralizumab)

Nucala (mepolizumab)

Xolair (omalizumab)

Sarclisa (isatuximab-irfc) – precertification required

effective 5/28/2020

Soliris (eculizumab) — precertification for the drug

and site of care required

Spinraza (nusinersen)

Spravato (esketamine)

Synagis (palivizumab)

Tegsedi (inotersen)

Ultomiris (Ravulizumab-cwvz)

Vectibix (panitumumab)

Viscosupplementation:

Durolane (Hyaluronic acid)

Euflexxa, Hyalgan, Genvisc, Supartz, TriVisc,

Visco 3 (sodium hyaluronate)

Gel-One (cross-linked hyaluronate)

Gelsyn

3, Hymovis (hyaluronic acid)

Monovisc,

Orthovisc (sodium

hyaluronate)

Synojoynt, Triluron (1% sodium hyaluronate)

Synvisc, Synvisc-One (hylan)

Xgeva (denosumab)

Xofigo (radium Ra 223 dichloride)

Yervoy (ipilimumab)

Zolgensma (onasemnogene abeparvovec-xioi) –

precertification for the drug and site of care

required

Proprietary

Special programs

BRCA genetic testing — 1-877-794-8720

See #9 in the General information section for

additional guidance.

Through our expanded national provider network:

•

Quest —1-866-436-3463

•

Ambry —1-866-262-7943

•

Baylor Miraca Genetics Laboratories, LLC—

1-800-411- GENE

•

BioReference, GeneDX, Genpath—

1-888-729-1206

•

Counsyl — 1-888-268-6795

•

Invitae — 1-800-436-3037

•

LabCorp —1-855-488-8750

•

Medical Diagnostic Laboratories—

1-877-269-0090

•

Myriad Genetics —1-800-469-7423

•

Progenity — 1-855-293-2639

Providers can use the BRCA form located

online

under

the

“Medical

Precertification”

section

to

submit

precertification

requests.

Find

genetic

counselors

online

—

for

a

list

of

our

contracted providers,

including

our telephonic

provider (Informed DNA), visit our

provider

directory.

Chiropractic precertification

See #9 in theGeneral informationsection for

additionalguidance.

Chiropractic precertification required only in

the states listed HMO-based plan members

only

AZ through

American Specialty Health

(ASH)1-800-972-4226

HMO-based

plan and group Medicare members

only

CA through

American Specialty Health

(ASH)1-800-972-4226

For all members (with commercial

and Aetna

Medicare Advantage plans

applicable to this

precertification list):

GA through American Specialty Health

(ASH) 1-800-972-4226

For

all members (with certain

commercial

plans,

and

Aetna

Medicare Advantage plans,

applicable

to

this precertification list):

DE, NJ, NY, PA, WV: through

National Imaging Associates

1-866-842-1542

Diagnostic Cardiology (cardiac rhythm

implantable devices, cardiac catheterization)

See

#9

and

#10

in

the

General

information

section

for additional

guidance.

Precertification for all members with plans

applicable to this precertification list unless

services are emergent:

•

Providers in all states where applicable, except

New York and northern New Jersey, should

contact MedSolutions DBA eviCore healthcare

to request preauthorization. You can reach

MedSolutions DBA eviCore healthcare:

-

Online at evicore.com

-

By phone at 1-888-693-3211between7 AM and 8

PM ET

- By fax at 1-844-822-3862, Monday

through Friday during normal

business hours, or as required by

federal or state regulations

•

Providers in New York and northern New

Jersey should contact 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

New York or 1-888-647-5940

for northern New Jersey

Hip and knee arthroplasties

See #9 and#10 in theGeneral information section

for additionalguidance.

Precertification for all members with plans

applicable to this precertification list unless

services are emergent:

•

Providers in all states where applicable, except

New York and northern New Jersey, should

contact MedSolutions DBA eviCore healthcare

to request preauthorization on. You can reach

MedSolutions DBA eviCore healthcare:

-

Online at evicore.com

-

By phone at 1-888-693-3211 between 7

AM and 8PM ET

- By fa x at 1-844-822-3862, Monday t hrough

Friday d uring normal business hours,

or as required by federal or state

regulations

Proprietary

Special programs, continued

Hip and knee arthroplasties, cont.

-

Providers in New York and northern New

Jersey should contact 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 New York

or

-

1-888-647-5940 for northern New Jersey

Home Health Care

Effective March 1, 2020, all Texas Medicare only (MEHMO

and MEPPO) home health-related requests for in-home

skilled nursing, physical therapy, occupational therapy,

speech therapy, a home health aide and medical social

work will require precertification through myNEXUS.

Providers in Texas should contact myNEXUS to request

precertification

•

Go to Portal.myNEXUScare.com/Account/Login

(registration is required).

•

Fax the form to 1-866-996-0077

•

Questions? Call myNEXUS Intake at 1-833-

585-6262 from 8 AM to 8 PM ET, Monday through

Friday or

•

Go to http://www.mynexuscare.com/aetna for

more details

Infertility program — 1-800-575-5999

See #9 in theGeneral informationsection for

additionalguidance.

Mentalhealth orsubstanceabuse services

precertification—See the member’sID card See

#9 in the General information section for additional

guidance.

National Medical Excellence Program

By phone at 1-877-212-8811 for the following:

•

Kymriah (tisagenlecleucel) andYescarta

(axicabtagene ciloleucel)

•

All major organ transplant evaluations and

transplants including, but not limited to,

kidney, liver, heart, lung and pancreas, and

bone marrow replacement or stem cell

transfer after high-dose chemotherapy

Outpatient physical therapy (PT) and

occupational

therapy (OT) precertification

See #9 and #10 in the General information section for

additional guidance.

Through OrthoNet 1-800-771-3205

•

CT— for all members with plans

applicable to this precertificationlist

Through Optum Health 1-800-344-4584 (only

Optum Health/Aetna-contracted providers

should call this number for questions and service

requests)

•

DC, GA, NC, SC, VA — For all members

with plans applicable to this

precertification list

•

Program also applies to members in Chicago, northern

IL and northwest IN (Lake and Porter counties)

•

Through National Imaging Associates 1-866-

842- 1542

•

DE, NJ, NY, PA, WV for members with

certain commercial plans, and Aetna

Medicare Advantage plans, applicable to

this precertification list

Pain management

See #9 and #10 in the General information section for

additional guidance.

Precertification for all members with plans applicable to

this precertification list unless services are emergent.

•

Providers in all states where applicable, except

New York and northern New Jersey, should

contact MedSolutions DBA eviCore healthcare

to request preauthorization on. You can reach

MedSolutions DBA eviCore healthcare:

-

Online at evicore.com

-

By phone at 1-888-693-3211between 7 AM and 8

PM ET

-

By fax at 1-844 -822-3862, Monday through

Friday during normal business hours,

or as required by federal or state

regulations

•

Providers in New York and northern New

Jersey should contact 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 New York or

1-888-647-5940 for northern New Jersey

Proprietary

Special programs, continued

Polysomnography (attended sleep studies)

See #9 and #10 in the General information section for

additional guidance.

Precertification for all members with plans

applicable to this precertification list when

performed in any

facility except inpatient,

emergency room and

observation bed status

•

Providers in all states where applicable,

except New York and northern New

Jersey, should contact 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 between7

AM and8 PM ET

-

By fax at 1- 844 -822-3862, Monday through

Friday

during normal business hours, or as

required by federal or state regulations

Polysomnography (attended sleep studies), cont.

•

Providers in New York and northern New Jersey

should contact 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 New York or

1-888- 647-5940 for northern New Jersey

Pre-implantation genetic testing — 1-800-575-5999

See #9 in the General information section for

additional guidance.

Radiology imaging

See #9 and #10 in the General information

section for additional guidance. Precertification

for all members with plans applicable to this

precertification list when performed in any

facility except inpatient, emergency room and

observation bed status.

•

Providers in all states where applicable,

except New York and northern New Jersey,

should contact MedSolutions DBA eviCore

healthcare to request preauthorization. You

can reach MedSolutions DBA eviCore

healthcare:

-

Online at evicore.com

-

By phone at 1-888-693-3211between7 AM and 8

PM ET

- By fax at 1-844-822-3862, Monday

through Friday during normal business

hours or as required by federal or state

regulations

•

Providers in New York and northern New

Jersey should contact CareCore National DBA

eviCore healthcare to request

preauthorization. You can reach CareCore

National DBA eviCore healthcare:

-

Online at evicore.com

-

By phone at1-888-622-7329 New York or

1-888-647-5940 for northern New Jersey

Radiation oncology

•

Complex

•

3D Conformal

•

Stereotactic Radiosurgery(SRS)

•

StereotacticBodyRadiation

Therapy (SBRT)

•

ImageGuided Radiation Therapy

(IGRT)

•

Intensity-Modulated Radiation

Therapy (IMRT)

•

ProtonBeam Therapy

•

NeutronBeam Therapy

•

Brachytherapy

•

Hyperthermia

•

Radiopharmaceuticals

See #9 and #10 in the General information section

for additional guidance.

Precertification for all members with HMO-based,

Aetna Medicare Advantage plans, and insured Aetna

commercial when performed in any facility except

inpatient, emergency room and observation bed

status.

•

Providers should contact 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

Proprietary

General information

1.

We collect information before electiveinpatient

admissions and/or selected ambulatory

procedures and services at the time of

precertification.

•

We’ll review precertification requests using

one of the following processes if the

member’s plan covers the services:

a.

Notification is a data-entry process. It

doesn’t require judgment or interpretation

for benefits coverage.

b.

Medical review – coverage determinations

made for items on the precert list are

utilization review decisions. We review

plan document s and (when applicable)

clinical information. This is how we

determine whether the requested service,

procedure, prescription drug or medical

device meets the clinical guidelines/criteria

for coverage.

•

We need to receive requests for

precertification before you provideservices.

c.

We encourage providers to submit

precertification requests at least two

weeks before the scheduled

services.

d.

To save you time, it’s best to submit

precertification requests and inquiries

electronically. This is the quickest way to

receive an authorization for services

requiring precertification. If you need help,

just call us. Look for the “precertification”

number on the member’s IDcard.

e.

If you don’t precertify the services on this

list, the member’s health plan (the “health

plan”), employer group or member won’t

be financially responsible for the

applicable service(s) if you provide those

services.

•

This material is for your information only. It’s

not meant to directtreatment decisions.

•

The review of items on this list may vary at

our discretion. If you receive approval for a

particular service or supply, it’s for that service

or supply only.

•

Services that don’t require precertification are

subject to the coverage terms of themember’s

plan.

•

For precertification in Texas,we use the utilization

review process to determine whether the requested

service, procedure, prescription drug or medical device

meets the company’s clinical criteria for coverage.

Precertification doesn’t mean payment for care or

services to fully insured HMO and PPO members as

defined by Texas law.

•

If member eligibility and plan coverage

for the procedure/ service you asked for

hasn’t changed, precertificationapprovals

are valid for six months in all states. This

is the case unless we tell you otherwise

when you receive the precertification

decision.

•

Every year, in January and July, we typically

update the precertification list. But we m ay

add new U.S. Food and Drug Administration

(FDA)-approved drugs to the list at different

times.

•

Visit Clinical Policy Bulletins and our

online provider directory.

•

The precertification process doesn’t include

verbal or written requests for information

about benefits or services not on the

precertification lists. Our staff members are

educated to determine whether a caller is

making an inquiry or requesting a coverage

decision/organization determination as part

of the intake process.

•

Find more information about notification and

coverage determinations.

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

insured members inIndiana.

3.

Innovation Health Insurance Company and Innovation

Health Plan, Inc. (Innovation Health) are affiliates of

Aetna Life Insurance Company (Aetna) and its affiliates.

Aetna and its affiliates provide certain management

services for InnovationHealth.

4.

Find more information about notification and

coverage determinations.

5.

We require precertification when Aetna or Innovation

Health is the secondary payer.

Proprietary

General information, continued

6.

We require precertification for maternity and

newbornstaysthat aremore thanthestandard

length of stay (LOS).Standard LOS for:

•

Vaginaldeliveries is threedaysor fewer

•

Cesarean section is five days or fewer

7.

Contact Aetna Pharmacy Management for

precertification of oral medications not on this

list.

•

See #9 in General information section for

additional guidance.

•

Their number is 1-800-414-2386

•

Call1-866-782-2779for information

on injectable medications notlisted

8.

For drugs administered orally, by injection

or infusion:

•

Drugs newly approvedby

the FDA may require

precertification review

•

Fully insured Texas and Louisiana

members continue to be covered for

drugs added to the precertificationlist

according to their current plan

design until their plan renewal date

•

Fully insured California HMO members

and fully insured Connecticut PPO

members covered for drugs added to the

precertification list continue to have

coverage.

a.

Drug coverage continues for these

California members as long as

the drug is appropriately

prescribed and considered safe

and effective treatment for the

medical condition

b.

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

10.

For members enrolled in Aetna Student Health

or Allina Health|Aetna precertification is not

required for the following outpatient services:

•

Diagnostic cardiology

•

Hip and knee arthroplasties

•

Physicaltherapy and occupationaltherapy

•

Pain management

•

Polysomnography

•

Radiology imaging

•

Radiation oncology

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.

aetna.com

23.03.882.1 G (5/20)

Proprietary