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Procedures, programs and drugs you must precertify

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 Foreign Ser vice Benefit Plan, MHBP and Rural Carrier Benefit Plan9. 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 ).

Procedures, programs and drugs you must precertify Participating provider precertification list Effective July 1, 2018 . Applies to. 1,2,3,4,9: Aetna

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Transcription of Procedures, programs and drugs you must precertify

1 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 Foreign Ser vice Benefit Plan, MHBP and Rural Carrier Benefit Plan9. 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 ).

2 Sutter Health and aetna Administrative Services LLC (Sutter Health | aetna ). 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. 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.

3 Home health care related services . secured provider website or using your Breast reconstruction/breast 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 1. Inpatient confinements (except hospice) Home dialysis loss For example, surgical and nonsurgical stays; stays Home health aide or certified nursing Gastroplasty/gastric bypass in a skilled nursing facility or rehabilitation facility; assistant Lipectomy or excess fat removal and maternity and newborn stays that exceed the Home infusion/injectable therapy Surgery for varicose veins, except stab standard length of stay (LOS)5 Home nursing care by registered or phlebectomy licensed nurse 2.

4 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 intervertebral disc surgery NOTE: Precertification for these services (cervical spine). 3. Ambulance is no longer required effective 6/1/2018 Cervical, lumbar and thoracic Precertification required for transportation 15. Hyperbaric oxygen therapy laminectomy/laminotomy by fixed-wing aircraft (plane). procedures 4. Autologous chondrocyte implantation, 16. Lower limb prosthetics, such as: Spinal fusion surgery Carticel Microprocessor-controlled lower limb prosthetics 26. Uvulopalatopharyngoplasty, including 5. Cochlear device and/or implantation laser-assisted procedures 17.

5 Nonparticipating freestanding ambulatory 6. Coverage at an in-network benefit level for 27. Ventricular assist devices surgical facility services, when referred by 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 8. Dialysis visits9 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.

6 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 drugs and medical injectables7,8. 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).

7 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 Profilnine (factor IX complex). Afstyla (antihemophilic factor [recombinant], single 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]).

8 Alprolix (coagulation factor IX [recombinant], Fc fusion Ixinity (coagulation factor IX [recombinant]) RiaSTAP (fibrinogen concentrate [human]). protein) 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]).

9 Eloctate (antihemophilic factor [recombinant], Fc NovoEight (turoctocog alfa). fusion protein) Xyntha, Xyntha Solof (antihemophilic factor 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.

10 - 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 (alglucosidase alfa) 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 (velaglucerase alfa). Aralast NP (alpha 1-proteinase Therapy (CAR-T) Contact Zomacton* (somatropin [rDNA origin]).)


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