Procedures, programs and drugs that require precertification
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Procedures, programs
and drugs that require
precertification
Participating provider precertification list
Starting September 1, 2021
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 U (9/21)For more information, read all general precertification guidelines
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) 19. Nonparticipating freestanding ambulatory
For example, surgical and nonsurgical stays, surgical facility services, when referred by
stays in a skilled nursing facility or rehabilitation a participating provider
facility, and maternity and newborn stays that 20. Orthognathic surgery procedures, bone
exceed the standard length of stay (LOS). (See grafts, osteotomies and surgical
#6 in the General Information section.) management of the temporomandibular
2. Ambulance joint
Precertification required for transportation by 21. Osseointegrated implant
fixed- wing aircraft (plane) 22. Osteochondral allograft/knee
3. Arthroscopic hip surgery to repair impingement 23. Private duty nursing
syndrome including labral repair 24. Proton beamradiotherapy
4. Autologous chondrocyte implantation Also see Special Programs; Radiation Oncology
5. Cataract surgery – precertification required 25. Reconstructive or other procedures that maybe
effective 7/1/2021. See special programs for considered cosmetic, such as:
additional guidance. • Blepharoplasty/canthoplasty
6. Chiari malformation decompression surgery • Breastreconstruction/breast enlargement
7. Cochlear device and/or implantation • Breast reduction/mammoplasty
8. Coverage at an in-network benefit level • Excision of excessive skin due to weight loss
for out-of-network provider or facility • Gastroplasty/gastricbypass
unless services are emergent. • Lipectomy or excess fat removal
Some plans have limited or no out-ofnetwork • Surgery for varicose veins,exceptstab phlebectomy
benefits. 26. Shoulder Arthroplasty including revision
9. Dental implants procedures
10. Dialysis visits 27. Spinal procedures, such as:
When a participating provider initiates a • Artificial intervertebral disc surgery (cervical spine)
request and dialysis is to be performed at a • Arthrodesis for spine deformity
nonparticipating facility. • Cervical laminoplasty
11. Dorsal column (lumbar) neurostimulators: • Cervical, lumbar and thoracic laminectomy and\or
trial orimplantation laminotomy procedures
12. Electric or motorized wheelchairs and • Kyphectomy
scooters • Laminectomy with rhizotomy
13. Endoscopic nasal balloon dilation procedures • Spinal fusion surgery – precertification required for
14. Functional endoscopic sinus surgery (FESS) sacroiliac joint fusion surgery effective 7/1/2021
15. Gender affirmation surgery • Vertebral corpectomy – precertification is required
16. Hyperbaric oxygen therapy effective 7/1/2021.
17. Infertility services and pre-implantation 28. Uvulopalatopharyngoplasty,
genetic testing including laser- assisted procedures
18. Lower limb prosthetics, such as 29. Ventricular assist devices
microprocessor-controlled lower limb 30. Video electroencephalograph (EEG)
prosthetics 31. Whole exome sequencing
ProprietaryDrugs and medical injectables
Blood-clotting factors (precertification for outpatient infusion of this drug class is required)
For the following services, providers should call 1-855-888-9046 for precertification, with the following exceptions:
• Precertification of pharmacy-covered specialty drugs
− For the Foreign Service Benefit Plan, call Express Scripts at 1-800-922-8279
− For MHBP and the Rural Carrier Benefit Plan, call CVS Caremark® at 1-800-237-2767
Advate (antihemophilic factor, human recombinant) Ixinity (coagulation factor IX [recombinant])
Adynovate (antihemophilic factor [recombinant],
Jivi [antihemophilic factor (recombinant),
PEGylated)
PEGylated-aucl]
Afstyla (antihemophilic factor [recombinant],
single chain) Koate, Koate-DVI (antihemophilic factor [human])
Kogenate FS (antihemophilic factor [recombinant])
Alphanate (antihemophilic factor/von Willebrand
Kovaltry (antihemophilic factor [recombinant])
factor complex [human])
Monoclate-P (antihemophilic factor [human])
AlphaNine SD (coagulation factor IX [human])
Mononine (coagulation factor IX [human])
Alprolix (coagulation factor IX [recombinant], Fc NovoEight (turoctocog alfa)
fusion protein)
NovoSeven RT (coagulation factor VIIa [recombinant])
Bebulin (factor IX complex) Nuwiq (simoctocog alfa)
BeneFix (coagulation factor IX [recombinant]) Obizur (antihemophilic factor [recombinant],
Coagadex (coagulation factor X [human]) porcine sequence)
Corifact (factor XIII concentrate [human])
Profilnine (factor IX complex)
Eloctate (antihemophilic factor [recombinant], Fc
Rebinyn (coagulation factor IX [recombinant],
fusion protein)
glycoPEGylated)
Esperoct [antihemophilic factor (recombinant),
Recombinate (antihemophilic factor [recombinant])
glycopegylated-exei]
RiaSTAP (fibrinogen concentrate [human])
FEIBA, FEIBA NF (anti-inhibitor coagulant
Rixubis (coagulation factor IX [recombinant])
complex)
Sevenfact (coagulation factor VIIa [recombinant]
Fibryga (fibrinogen, human)
jncw)
Helixate FS (antihemophilic factor [recombinant])
Tretten (coagulation factor XIII a-subunit
Hemlibra (emicizumab-kxwh)
[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])
Idelvion (antihemophilic factor [recombinant])
Xyntha, Xyntha Solof (antihemophilic factor
[recombinant])
ProprietaryOther 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 precertificationof pharmacy-covered specialty drugs (notedwith *) 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 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 RuralCarrierBenefitPlan:
− 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 Botulinum toxins, cont.
Medicare Advantage members only
Xeomin (incobotulinumtoxinA)
Acthar Gel/H. P. Acthar (corticotropin)
Cablivi (caplacizumab-yhdp)
Adakveo (crizanlizumab-tmca) – precertification for
Calcitonin Gene-Related Peptide (CGRP) receptor
the drug and site of care required
inhibitors
Adcetris (brentuximab vedotin)
Vyepti (eptinezumab-jjmr) — precertification for the
Aduhelm (aducanumab-avwa) — precertification for drug and site of care required
drug and site of care required effective 8/3/2021
Cardiovascular — PCSK9 inhibitors:
Alpha 1-proteinase inhibitor (human)
Praluent* (alirocumab)
(precertification for the drug and site of care
required): Repatha* (evolocumab)
Aralast NP (alpha 1-proteinase inhibitor) Chimeric Antigen Receptor T-Cell Therapy (CAR-T)
Glassia (alpha 1-proteinase inhibitor) — Contact National Medical Excellence at
Prolastin-C (alpha 1-proteinase inhibitor) 1-877-212-8811
Zemaira (alpha 1- proteinase inhibitor) Abecma (idecabtagene vicleucel) —
Amyotrophic Lateral Sclerosis (ALS) drugs: precertification 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 (bevacizumab), 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 required
Bendeka (bendamustine HCl) effective 5/7/2021
Benlysta (belimumab) — precertification for the Crysvita (burosumab) — precertification for the
drug and site of care required drug and site of care required
Besponsa (inotuzumab ozogamicin) Cyramza (ramucirumab)
Blenrep (belantamab mafodotin-blmf) Danyelza (naxitamab-gqgk) — precertification
required effective 3/1/2021
Bortezomib — precertification required effective
9/1/2021 for multiple myeloma only Darzalex (daratumumab)
Botulinum toxins: Darzalex Faspro (daratumumab and hyaluronidase
fihj)
Botox (onabotulinumtoxinA)
Dysport (abobotulinumtoxinA) Dupixent* (dupilumab)
Myobloc (rimabotulinumtoxinB) Empliciti (elotuzumab)
ProprietaryEnzyme replacement drugs: Granulocyte-colony stimulating factors, cont.
Aldurazyme (laronidase) — precertification Nivestym (filgrastim-aafi)
for the drug and site of care required Nyvepria (pegfilgrastim-apgf) — precertification
Brineura (cerliponase alfa) required effective 2/1/2021
Cerezyme (imiglucerase) — precertification for Udenyca (pegfilgrastim-cbvq)
the drug and site of care required.
Zarxio (filgrastim-sndz)
Elaprase (idursulfase) — precertification
Ziextenzo (pegfilgrastim-bmez)
for the drug and site of care required
Growth hormone:
Elelyso (taliglucerase alfa) —
precertification for the drug and site of Genotropin* (somatropin)
care required Humatrope* (somatropin)
Fabrazyme (agalsidase beta) — Increlex* (mecasermin)
precertification for the drug and site of Norditropin*(somatropin)
care required Nutropin AQ* (somatropin)
Kanuma (sebelipase alfa) — precertification for the Omnitrope* (somatropin)
drug and site of care required Saizen* (somatropin)
Lumizyme (alglucosidase alfa) — precertification Serostim* (somatropin)
for the drug and site of care required Sogroya* (somapacitan-beco) – precertification
Mepsevii (vestronidase alfa-vjbk) — precertification required effective 2/11/2021
for the drug and site of care required Zomacton* (somatropin [rDNA origin])
Naglazyme (galsulfase) — precertification for Zorbtive* (somatropin)
the drug and site of care required
Hereditary angioedema agents:
Strensiq (asfotase alfa)
Berinert (C1esterase inhibitor)
Vimizim (elosulfase alfa) — precertification for
Cinryze (C1 esterase inhibitor) – precertification for
the drug and site of care required
the drug and site of care required
VPRIV (velaglucerase alfa) — precertification
Firazyr (icatibant acetate)
for the drug and site of care required
Haegarda (C1 esterase inhibitor subcutaneous
Erbitux (cetuximab)
[human])
Erythropoiesis-stimulating agents:
Kalbitor (ecallantide)
Aranesp (darbepoetin alfa)
Ruconest (C1 esterase inhibitor)
Epogen (epoetin alfa) Takhzyro (lanadelumab)
Mircera (epoetin beta) HER2 receptor drugs:
Procrit (epoetin alfa)
Enhertu (fam-trastuzumab deruxtecan-nxki)
Retacrit (recombinant human erythropoietin)
Herceptin (trastuzumab)
Evkeeza (evinacumab-dgnb) — precertification
Herceptin Hylecta (trastuzumab and
for the drug and site of care required effective
hyaluronidase-oysk)
5/7/2021
Herzuma (trastuzumab-pkrb)
Evrysdi (risdiplam)
Kadcyla (ado-trastuzumab emtansine)
Feraheme (ferumoxytol)
Kanjinti (trastuzumab-anns)
Fusilev (levoleucovorin)
Margenza (margetuximab-cmkb) – precertification
Gattex (teduglutide) required effective 4/1/2021
Givlaari (givosiran) – precertification for drug Ogivri (trastuzumab-dkst)
and site of care required
Ontruzant (trastuzumab-dttb)
Granulocyte-colony stimulating factors:
Perjeta (pertuzumab)
Fulphila (pegfilgrastim-jmdb)
Phesgo (pertuzumab/trastuzumab/hyaluronidase
Granix (tbo-filgrastim) zzxf)
Leukine (sargramostim) Trazimera (trastuzumab-qyyp)
Neulasta (pegfilgrastim) Ilaris* (canakinumab)
Neupogen (filgrastim) Imlygic (talimogene laherparepvec)Immunoglobulins (precertification for the drug Immunologic agents, cont.
and site of care required): Rinvoq (upadacitinib)
Asceniv (immune globulin) Rituxan (rituximab)
Bivigam (immune globulin) Rituxan Hycela (rituximab/hyaluronidase human)
Carimune NF (immune globulin) Ruxience (rituximab-pvvr)
Cutaquig (immune globulin) Siliq* (brodalumab)
Cuvitru (immune globulin SC [human]) Simponi* (golimumab)
Flebogamma (immune globulin)
Simponi Aria (golimumab) — precertification for
GamaSTAN S/D (immune globulin) the drug and site of care required
Gammagard, Gammagard S/D (immune globulin) Skyrizi* (risankizumab-rzaa)
Gammaked (immune globulin) Stelara* (ustekinumab)
Gammaplex (immune globulin) Stelara IV (ustekinumab)
Gamunex-C (immune globulin) Taltz* (ixekizumab)
Hizentra (immune globulin) Tremfya* (guselkumab)
HyQvia (immune globulin) Truxima (rituximab-abbs)
Octagam (immune globulin) Xeljanz*, Xeljanz XR* (tofacitinib)
Panzyga (immune globulin) Injectable infertility drugs:
Privigen (immune globulin) chorionic gonadotropin
Xembify (immune globulin) Bravelle (urofollitropin)
Immunologic agents: Cetrotide (cetrorelix acetate)
Avsola (infliximab-axxq) — precertification Follistim AQ (follitropin beta)
for the drug and site of care required
Ganirelix AC (ganirelix acetate)
Actemra (tocilizumab) — precertification for Gonal-f (follitropin alfa)
the drug and site of care required
Gonal-f RFF (follitropin alfa)
Actemra* SC (tocilizumab)
Menopur (menotropins)
Cimzia* (certolizumab pegol)
Novarel (chorionic gonadotropin)
Cosentyx* (secukinumab)
Ovidrel (choriogonadotropin alfa)
Enbrel* (etanercept)
Pregnyl (chorionic gonadotropin)
Enspryng* (satralizumab)
Injectafer (ferric carboxymaltose injection)
Entyvio (vedolizumab) — precertification for the
drug and site of care required Jelmyto (mitomycin)
Humira* (adalimumab) Khapzory (levoleucovorin)
Ilumya* (tildrakizumab) Kyprolis (carfilzomib) — precertification required
effective 9/1/2021 for multiple myeloma only
Inflectra (infliximab-dyyb) — precertification for
the drug and site of care required Lartruvo (olaratumab)
Kevzara* (sarilumab) Luteinizing hormone-releasing hormone
(LHRH) agents:
Kineret* (anakinra)
Camcevi (leuprolide mesylate) — precertification
Olumiant* (baricitinib)
required effective 8/1/2021
Orencia SQ* (abatacept)
Eligard (leuprolide acetate)
Orencia IV (abatacept) — precertification
Firmagon (degarelix)
for the drug and site of care required
Lupron Depot (leuprolide acetate), 7.5 mg —
Otezla* (apremilast)
precertification required for oncology
Remicade (infliximab) — precertification indications only
for the drug and site of care required
Trelstar (triptorelin pamoate)
Renflexis (infliximab-abda) — precertification
Zoladex (goserelin)
for the drug and site of care required
Lumoxiti (moxetumomab pasudotox-tdfk)
Riabni (rituximab-arrx) — precertification
required effective 4/2/2021 Makena (hydroxyprogesterone caproate)
Monjuvi (tafasitamab-cxix)Multiple sclerosis drugs: Ophthalmic injectables, cont.
Aubagio* (teriflunomide) Luxturna (voretigene neparvovec-rzyl) —
Avonex* (interferon beta-1a) precertification for the drug and site of care
Bafiertam* (monomethyl fumarate) required
Betaseron* (interferon beta-1b) Macugen (pegaptanib)
Copaxone* (glatiramer acetate) Tepezza (teprotumumab-trbw) – precertification
for the drug and site of care required
Extavia* (interferon beta-1b)
Osteoporosis drugs:
Gilenya* (fingolimod hydrochloride)
Bonsity* (teriparatide)
Glatopa* (glatiramer acetate injection)
Evenity* (romosozumab-aqqg)
Kesimpta* (ofatumumab)
Forteo* (teriparatide)
Lemtrada (alemtuzumab), — precertification
for the drug and site of care required Miacalcin (calcitonin)
Mavenclad* (cladribine) Prolia (denosumab)
Mayzent* (siponimod) Tymlos* (abaloparatide)
Ocrevus (ocrelizumab) — precertification for Oxlumo (lumasiran) — precertification for the drug
the drug and site of care required and site of care required effective 3/17/2021
Plegridy* (peginterferon beta-1a) Padcev (enfortumab vedotin)
Ponvory* (ponesimod) — precertification Parsabiv (etelcalcetide)
required effective 5/1/2021 PD1/PDL1 drugs (precertification for the drug
Rebif* (interferon beta-1a) and site of care required):
Tecfidera* (dimethyl fumarate) Bavencio (avelumab)
Tysabri(natalizumab) — precertification for Imfinzi (durvalumab)
the drug and site of care required Jemperli (dostarlimab-gxly) — precertification for
Vumerity* (diroximel fumarate) the drug and site of care required effective
7/1/2021
Zeposia* (ozanimod)
Keytruda (pembrolizumab)
Muscular dystrophy drugs:
Libtayo (cemiplimab-rwlc)
Amondys 45 (casimersen) — precertification
for the drug and site of care required Opdivo (nivolumab)
effective 6/1/2021 Tecentriq (atezolizumab)
Exondys 51 (eteplirsen) — precertification Pepaxto (melphalan flufenamide) — precertification
for the drug and site of care required required effective 6/1/2021
Emflaza* (deflazacort) Polivy (polatuzumab vedotin-piiq)
Viltepso (viltolarsen) — precertification for Provenge (sipuleucel-T)
the drug and site of care required Pulmonary arterial hypertension drugs:
Vyondys 53 (golodirsen) — precertification All epoprostenol sodium and sildenafil citrate*
for the drug and site of care required Adcirca* (Alyq, tadalafil)
Mvasi (bevacizumab-awwb) — precertification Adempas* (riociguat)
required for oncology indications only Flolan (epoprostenol sodium)
Myalept (metreleptin) Letairis* (ambrisentan)
Natpara (parathyroid hormone) Opsumit* (macitentan)
Nulibry (fosdenopterin) — precertification Orenitram* (treprostinil diolamine)
required effective 6/1/2021 Remodulin (treprostinil sodium)
Onpattro (patisiran) — precertification for Revatio* (sildenafil citrate)
the drug and site of care required Tracleer* (bosentan)
Ophthalmic injectables: Tyvaso (treprostinil)
Beovu (brolucizumab-dbll) Uptravi* (selexipag)
Eylea (aflibercept) Veletri (epoprostenol sodium)
Lucentis (ranibizumab) Ventavis (iloprost)Reblozyl (luspatercept) Ultomiris (Ravulizumab-cwvz) —
Respiratory injectables (precertification precertification for the drug and site of care
required and site of care required): required
Cinqair (reslizumab) Uplizna (inebilizumab-cdon) — precertification
Fasenra (benralizumab) for the drug and site of care required
Nucala (mepolizumab) Vectibix (panitumumab)
Velcade (bortezomib) — precertification
Xolair (omalizumab)
required effective 9/1/2021 for multiple
Rybrevant (amivantamab-vmjw) — myeloma only
precertification required effective 8/6/2021
Viscosupplementation:
Ryplazim (plasminogen, human-tvmh) —
Durolane (Hyaluronic acid)
precertification required effective 8/1/2021
Euflexxa, Hyalgan, Genvisc, Supartz FX,
Sarclisa (isatuximab-irfc)
TriVisc, Visco 3 (sodium hyaluronate)
Soliris (eculizumab) — precertification for the
Gel-One (cross-linked hyaluronate)
drug and site of care required
Gelsyn3, Hymovis (hyaluronic acid)
Somatostatin agents:
Monovisc, Orthovisc (sodium hyaluronate)
Bynfezia (octreotide)
Synojoynt, Triluron (1% sodium hyaluronate)
Sandostatin (octreotide)
Synvisc, Synvisc-One (hylan)
Sandostatin LAR (octreotide acetate)
Xgeva (denosumab)
Signifor (pasireotide)
Xofigo (radium Ra 223 dichloride)
Signifor LAR (pasireotide)
Yervoy (ipilimumab) — precertification for the drug
Somatuline (lanreotide)
and site of care required
Somavert (pegvisomant)
Zirabev (bevacizumab-bvzr) — precertification
Spinraza (nusinersen) — precertification
required for oncology indications only
required and effective 7/1/2021 site of care
Zolgensma (onasemnogene abeparvovec-xioi) –
required
precertification for the drug and site of care
Spravato (esketamine)
required
Synagis (palivizumab)
Zulresso (brexanolone)
Tegsedi (inotersen)
Zynlonta (loncastuximab tesirine-lpyl) —
Treanda (bendamustine HCl) precertification required effective 7/1/2021
Trodelvy (sacituzumab govitecan-hziy)Special programs, continued
BRCA genetic testing — 1-877-794-8720 Cataract surgery
See #9 in the General information section for For all Georgia Medicare only (HMO and PPO)
more guidance. cataract surgery related requests, providers should
Through our expanded national provider network: contact iCare Health Solutions to request
• Quest — 1-866-436-3463 preauthorization. You can reach iCare at
1-844-210-7444.
• Ambry — 1-866-262-7943
For all Florida Medicare only (HMO and POS) cataract
• Baylor Miraca Genetics Laboratories, LLC—
1-800-411- GENE (1-800-411-4363) surgery related requests, providers should contact
• BioReference, GeneDX, Genpath— iCare Health Solutions to request preauthorization.
1-888-729-1206 You can reach iCare at
• Invitae — 1-800-436-3037 1-855-373-7627.
• LabCorp— 1-855-488-8750
• Medical Diagnostic Laboratories—1-877-269-0090 Diagnostic Cardiology (cardiac rhythm implantable
• Myriad Genetics —1-800-469-7423 devices, cardiac catheterization)
• Progenity — 1-855-293-2639 See #9 and #10 in theGeneral information
Providers can use the BRCA form located online section for more guidance.
under the “Medical Precertification” section to
Precertification for all members with plans
submit precertification requests.
applicable to this precertification list
unless services are emergent:
Find genetic counselors online
• Providers in all states where applicable,
For a list of our contracted providers, including our
except New York and northern New
telephonic provider (Informed DNA), visit our
Jersey, should contact MedSolutions DBA
provider directory.
eviCore healthcare to request
preauthorization. You can reach
Chiropractic precertification
MedSolutions DBA eviCore healthcare:
See #9 in theGeneral informationsectionfor
- Online at evicore.com
additionalguidance.
- By phone at 1-888-693-3211 between7 AM
Chiropractic precertification required only in the and 8 PM ET
states listed HMO-based plan members only - By fax at 1-844-822-3862, Monday
AZ through American Specialty Health through Friday during normal
(ASH)1-800-972-4226 business hours, or as required
HMO-based plan and group Medicare members only by federal or state regulations
CA through American Specialty Health • Providers in New York and northern
(ASH)1-800-972-4226 New Jersey should contact CareCore
For all members (with commercial and Aetna Medicare National DBA eviCore healthcare to
Advantage plans applicable to this precertification list): request preauthorization. You can reach
CareCore National DBA eviCore
GA through American Specialty Health
healthcare:
(ASH) 1-800-972-4226
- Onlineat evicore.com
For all members (with certain commercial plans, and - By phone at 1-888-622-7329 for New York or
Aetna Medicare Advantage plans, applicable to this 1-888-647-5940 for northern New Jersey
precertification list):
DE, NJ, NY, PA, WV: through
National Imaging Associates
1-866-842-1542Special programs, continued
Hip and knee arthroplasties Infertility program — 1-800-575-5999
Note: Effective 08/30/2021 these procedures See #9 in the General information section for additional
codes will be handled by Aetna/CVS and no guidance.
longer handled by eviCore.
Mentalhealth orsubstance abuse services
See #9 and #10 in theGeneral information precertification—See the member’s ID card See #9 in
section for more guidance. the General information section for additional guidance.
Precertification for all members with plans
applicable to this precertificationlist unless National Medical Excellence Program
services are emergent: By phone at 1-877-212-8811 for the following:
• Providers in all states where applicable, • Abecma (idecabtagene vicleucel), Breyanzi
except New York and northern New (lisocabtagene maraleucel), Kymriah
Jersey, should contact MedSolutions (tisagenlecleucel), Tecartus (brexucabtagene
DBA eviCore healthcare to request autoleucel) and Yescarta (axicabtagene
preauthorization on. You can reach ciloleucel)
MedSolutions DBA eviCore healthcare: • All major organ transplant evaluations and
- Online at evicore.com transplants including, but not limited to, kidney,
- By phone at 1-888-693-3211 liver, heart, lung and pancreas, and bone marrow
between 7 AM and 8 PM ET replacement or stem cell transfer after high-dose
By fax at 1-844-822-3862, Monday chemotherapy
through Friday during normal
business hours, or as required by Outpatient physical therapy (PT) and occupational
federal or state regulations therapy (OT) precertification
- Providers in New York and northern New
See #9 and #10 in the General information section for
Jersey should contact CareCore National DBA
additional guidance.
eviCore healthcare to request preauthorization.
Through OrthoNet 1-800-771-3205
You can reach CareCore National DBA eviCore
• CT— for all members with plans applicable
healthcare:
- Online at evicore.com to this precertification list
- By phone at 1-888-622-7329 for New York Through Optum Health 1-800-344-4584 (Only
or Optum Health/Aetna-contracted providers
- 1-888-647-5940 for northern New should call this number for questions and service
Jersey requests.)
• DC, GA, NC, SC, VA — For all members with
Home health care plans applicable to this precertification list
All Texas, Georgia, Virginia, and Oklahoma Medicare • Program also applies to members in Chicago, northern
Advantage (excluding Oklahoma and Virginia Dual IL and northwest IN (Lake and Porter counties)
Special Needs Plans) home health-related requests for in- • Through National Imaging Associates
home skilled nursing, physical therapy, occupational
1-866-842- 1542
therapy, speech therapy, a home health aide and medical
social work will require precertification through • DE, NJ, NY, PA, WV for members with certain
myNEXUS. commercial plans, and Aetna Medicare Advantage
Providers in these states should contact myNEXUS to plans, applicable to this precertification list
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 detailsSpecial programs, continued
Pain management Polysomnography (attended sleep studies), cont.
See #9 and #10 in the General information section for • Providers in New York and northern New Jersey should
additional guidance. contact CareCore National DBA eviCore healthcare to
Precertification for all members with plans applicable request preauthorization. You can reach CareCore
National DBA eviCore healthcare:
to this precertification list unless services are
- Online at evicore.com
emergent.
- By phone at 1-888-622-7329 for New York or
• Providers in all states where applicable, 1-888-647-5940 for northern New Jersey
except New York and northern New Jersey,
should contact MedSolutions DBA eviCore Pre-implantation genetic testing—
healthcare to request preauthorization on. 1-800-575-5999
You can reach MedSolutions DBA eviCore See #9 in the General information sectionfor
healthcare: more guidance.
- Online at evicore.com
- By phone at 1-888-693-3211between 7 AM and 8
PM ET Radiology imaging
- By fax at 1-844 -822-3862, Monday through See #9 and #10 in the General information
Friday, during normal business section for more guidance. Precertification for all
hours, or as required by federal members with plans applicable to this
or state regulations precertification list when performed in any facility
• Providers in New York and northern New except inpatient, emergency room and
Jersey should contact CareCore National observation bed status.
DBA eviCore healthcare to request • Providers in all states where applicable,
preauthorization. You can reach except New York and northern New Jersey,
CareCore National DBA eviCore should contact MedSolutions DBA eviCore
healthcare: healthcare to request preauthorization.
- Online at evicore.com You can reach MedSolutions DBA eviCore
- By phone at 1-888-622-7329 for New York or healthcare:
1-888-647-5940 for northern New Jersey - Online at evicore.com
- By phone at 1-888-693-3211 between7 AM and 8
Polysomnography (attended sleep studies) PM ET
See #9 and #10 in the General information section for - By fax at 1-844-822-3862, Monday
more guidance. through Friday during normal business
Precertification for all members with plans hours or as required by federal or state
applicable to this precertification list when regulations
performed in any • Providers in New York and northern New
facility except inpatient, Jersey should contact CareCore National DBA
emergency room and observation eviCore healthcare to request preauthorization.
bed status You can reach CareCore National DBA
• Providers in all states where applicable, eviCore healthcare:
except New York and northern New - Online at evicore.com
Jersey, should contact MedSolutions - By phone at 1-888-622-7329 New York or
DBA eviCore healthcare to request 1-888-647-5940 for northern New Jersey
preauthorization. You can reach
MedSolutions DBA eviCore healthcare:
- Online at evicore.com
- By phone at 1-888-693-3211 between
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 regulationsSpecial programs, continued
Radiation oncology Whole Exome Sequencing (WES)
• Complex Through our expanded national provider network:
• 3D Conformal • Quest — 1-866-436-3463
• Stereotactic Radiosurgery(SRS) • Ambry — 1-866-262-7943
• StereotacticBody • Baylor Miraca Genetics Laboratories, LLC —
Radiation Therapy 1-800-411- GENE (1-800-411-4363)
(SBRT) • BioReference, GeneDX, Genpath — 1-888-729-1206
• ImageGuided Radiation Therapy • Invitae — 1-800-436-3037
(IGRT) • LabCorp — 1-866-248-1265
• Intensity-Modulated Providers can use the Whole Exome Sequencing
Radiation Therapy (IMRT) (WES) form located online under the “Medical
• ProtonBeam Therapy Precertification” section to submit precertification
• NeutronBeam Therapy requests.
• Brachytherapy
• Hyperthermia
• Radiopharmaceuticals
See #9 and #10 in theGeneral information
section for additionalguidance.
Precertification for all members with HMO-
based, AetnaMedicare Advantageplans,and
insuredAetna 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 1-888-622-7329General information
1. We collect information before elective inpatient • For precertification in Texas,we use the utilization
admissions and/or selected ambulatory review process to determine whether the requested
procedures and services at the time of service, procedure, prescription drug or medical device
precertification. meets the company’s clinical criteria for coverage.
• We’ll review precertification requests using Precertification doesn’t mean payment for care or
one of the following processes if the services to fully insured HMO and PPO members as
member’s plan covers the services: defined by Texas law.
− Notification is a data-entry process. It
• If member eligibility and plan coverage
doesn’t require judgment or interpretation
for the procedure/ service you asked for
for benefits coverage.
hasn’t changed, precertificationapprovals
− Medical review – Coverage are valid for six months in all states. This
determinations made for items on the is the case unless we tell you otherwise
precertification list are utilization review when you receive the precertification
decisions. We review plan document s decision.
and (when applicable) clinical • Every year, in January and July, we
information. This is how we determine typically update the precertification list. But
whether the requested service, we m ay add new FDA-approved drugs to the
procedure, prescription drug or medical list at different times.
device meets the clinical guidelines/criteria
Visit Clinical Policy Bulletins and our
•
for coverage.
online provider directory.
• We need to receive requests for
• The precertification process doesn’t include
precertification before you provide services.
verbal or written requests for information
− We encourage providers to submit about benefits or services not on the
precertification requests at least two precertification lists. Our staff members are
weeks before the scheduled educated to determine whether a caller is
services. making an inquiry or requesting a coverage
− To save you time, it’s best to submit decision/organization determination as part
precertification requests and inquiries of the intake process.
electronically. This is the quickest way to • Find more about notification and coverage
receive an authorization for services determinations.
requiring precertification. If you need help, 2. We don’t offer all plans in all service areas, and not
just call us. Look for the “precertification” all plans include all services listed. For example,
number on the member’s ID card. precertification programs don’t apply to fully insured
− If you don’t precertify the services on this
members in Indiana.
list, the member’s health plan (the “health
3. Innovation Health Insurance Company and Innovation
plan”), employer group or member won’t
Health Plan, Inc. (Innovation Health) are affiliates of
be financially responsible for the
Aetna Life Insurance Company (Aetna) and its affiliates.
applicable service(s) if you provide those
Aetna and its affiliates provide certain management
services.
services for InnovationHealth.
• This material is for your informationonly. It’s
4. Find more information about notification and
not meant to directtreatment decisions.
coverage determinations.
• The review of items on this list may vary at
our discretion. If you receive approval for a 5. We require precertification when Aetna or Innovation
particular service or supply, it’s for that service Health is the secondary payer.
or supply only.
• Services that don’t require precertification are
subject to the coverage terms of themember’s
plan.
ProprietaryGeneral information, continued
6. We require precertification for maternity and − Drug coverage continues for these
newborn stays that are more than the standard Connecticut members as long as the drug
length of stay (LOS). Standard LOS for: is medically necessary and more medically
• Vaginaldeliveries is threedaysor fewer beneficial than other covered drugs
• Cesarean section is five daysor fewer • The prescribing provider must respond to requests for
7. Contact Aetna Pharmacy Management for more information. For fully insured members with a
precertification of oral medications not on this Colorado state contract, we’ll approve or deny
list. precertification requests within time frames mandated by
• See #9 in General informationsection for
Colorado Regulation 4-2-49 RX Prior Authorization.
additional guidance.
• Their number is 1-800-414-2386. 9. For members enrolled in Foreign Service Benefit Plan,
MHBP or Rural Carrier Benefit Plan: Precertification is
• Call1-866-782-2779 for information
not required for cardiac catheterization, cardiac imaging,
on injectable medications notlisted.
chiropractic services, transthoracic echocardiogram or
8. For drugs administered orally, by injection or physical/occupational therapy
infusion: • Visit online provider directories: Foreign Service
• Drugs newly approvedby
Benefit Plan; MHBP; Rural Carrier Benefit Plan
the FDA may require • Except as notedfor drugs and medical injectables
precertification review. and special programs, for all other services:
• Fully insured Texas and Louisiana
− Foreign Service Benefit Plan, call
members continue to be covered for
1-800-593-2354
drugs added to the precertification list
− MHBP, call 1-800-410-7778
accordingto their current plan
design until their plan renewal date. − Rural Carrier Benefit Plan, call
• Fully insured California HMO members 1-800-638-8432
and fully insured ConnecticutPPO 10. For members enrolled in Aetna Student Health
members covered for drugs added to the or Allina Health|Aetna precertification is not
required for the following outpatient services:
precertification list continue to have
coverage. • Diagnostic cardiology
− Drug coverage continues forthese • Hip and knee arthroplasties
California members as long as the • Physicaltherapy and occupationaltherapy
drug is appropriately prescribed • Pain management
and considered safe and effective • Polysomnography
treatment for the medical
• Radiology imaging
condition.
• 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
© 2021 Aetna Inc.
23.03.882.1 U (9/21)
ProprietaryYou can also read
