Participating Provider Precertification List

Transcription

1 Participating Provider Precertification List Effective August 1, 2016 Reference all general precertification information. Applies to all Coventry commercial and Medicare benefit plans that include a precertification requirement unless noted in the plan sponsor deviation section. 1. Ambulance Transportation by fixed-wing aircraft (plane) Elective (non-emergency) transportation by ground, ambulance or medical van for Medicare Advantage plan members only 2. Autologous chondrocyte implantation, Carticel 3. BRCA testing 4. Cochlear device and/or implantation 5. Dental implants 6. Dialysis visits 7. Dorsal column (lumbar) neurostimulators: trial or implantation 8. Electric or motorized wheelchairs and scooters 9. Gastrointestinal (GI) tract imaging through capsule endoscopy 10. Gender reassignment 11. Hip to repair impingement syndrome 12. Home health care related services Private duty nursing 13. Hyperbaric oxygen 14. Infertility services and pre-implantation genetic testing 15. Inpatient confinements (with the exception of hospice) For example, surgical and nonsurgical confinements; confinements in a skilled nursing facility or rehabilitation facility; and maternity and newborn confinements that exceed the standard length of stay (LOS) 16. Lower limb prosthetics 17. Nonparticipating freestanding ambulatory surgical facility services, when referred by a participating provider 18. Observation stays more than 24 hours 19. Orthognathic procedures, bone grafts, osteotomies and surgical of the temporomandibular joint 20. Osseointegrated implant 21. Osteochondral allograft/knee 22. Power morcellation with uterine myomectomy, with hysterectomy or for removal of uterine fibroids 23. Proton beam radio 24. Reconstructive or other procedures that may be considered cosmetic Blepharoplasty/canthoplasty Breast reconstruction/breast enlargement Breast reduction/mammoplasty Cervicoplasty Excision of excessive skin due to weight loss Gastroplasty/gastric bypass Lipectomy or excess fat removal Surgery for varicose veins, except stab phlebectomy 25. Referral or use of nonparticipating physician or provider for non-emergent services, unless the member understands and consents to the use of a nonparticipating provider under their out-ofnetwork benefits when available in their plan 26. Spinal procedures Artificial intervertebral disc Cervical, lumbar and thoracic laminectomy/laminotomy procedures Spinal fusion 27. Uvulopalatopharyngoplasty, including laser-assisted procedures 28. Ventricular assist devices 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, Coventry Health and Life Insurance Company and their affiliates (Aetna) K (8/16)

2 Drugs and medical injectables Blood-clotting factors (precertification for outpatient infusion of this drug class is required): Advate (antihemophilic factor, human recombinant) Adynovate (antihemophilic factor [recombinant], PEGylated) precertification effective 1/14/2016 Afstyla (antihemophilic factor [recombinant], single chain) precertification effective 8/2/2016 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) Bebulin VH (factor IX complex) BeneFix (coagulation factor IX [recombinant]) Coagadex (coagulation factor X [human]) precertification effective 1/14/2016 Corifact (factor XIII concentrate [human]) Eloctate (antihemophilic factor [recombinant], Fc fusion protein) Feiba NF (anti-inhibitor coagulant complex) Helixate (antihemophilic factor [recombinant]) Hemofil M (antihemophilic factor [human]) Humate-P (antihemophilic factor/von Willebrand factor complex [human]) Idelvion (antihemophilic factor [recombinant]) precertification effective 6/3/2016 Ixinity (coagulation factor IX [recombinant]) Koate-DVI (antihemophilic factor [human]) Kogenate FS (antihemophilic factor [recombinant]) Kovaltry (antihemophilic factor [recombinant]) precertification effective 6/3/2016 Monoclate-P (antihemophilic factor [human]) Mononine (coagulation factor IX [human]) NovoEight (turoctocog alfa) NovoSeven RT (coagulation factor VIIa [recombinant]) Nuwiq (human coagulation factor VIII rdna, simoctocog alfa) Obizur (antihemophilic factor [recombinant]) Profilnine (factor IX complex) 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]) precertification effective 2/12/2016 Wilate (von Willebrand factor/coagulation factor VIII complex [human]) Xyntha (antihemophilic factor [recombinant]) Other drugs and medical injectables Access drug-specific medication forms online at and fax them to the number on the form. Providers may also call for questions regarding authorizations submitted by fax (option 1 for commercial plan members and option 2 for Medicare plan members). Acthar Gel (corticotropin) Botulinum toxins: Enzyme replacement drugs: Erbitux (cetuximab) Actimmune (interferon gamma-1b) Adcetris (brentuximab vedotin) Alpha 1-proteinase inhibitor (human): Aralast NP (alpha 1-proteinase inhibitor) Glassia (alpha 1-proteinase inhibitor) Prolastin-C (alpha 1-proteinase inhibitor) Zemaira (alpha 1-proteinase inhibitor) Antiemetics: Aloxi IV (palonosetron HCl) Anzemet IV (dolasetron mesylate) Emend IV (fosaprepitant dimeglumine) Benlysta (belimumab) Botox (onabotulinumtoxina) Dysport (abobotulinumtoxina) Myobloc (rimabotulinumtoxinb) Xeomin (incobotulinumtoxina) Cardiovascular PCSK9 inhibitors: Praluent (alirocumab) Repatha (evolocumab) Cyramza (ramucirumab) Darzalex (daratumumab) precertification effective 3/1/2016 Empliciti (elotuzumab) precertification effective 2/12/2016 Aldurazyme (laronidase) Cerezyme (imiglucerase) Elaprase (idursulfase) Elelyso (taliglucerase alfa) Fabrazyme (agalsidase beta) Kanuma (sebelipase alfa) precertification effective 1/14/2016 Lumizyme (alglucosidase alfa) Myozyme (alglucosidase alfa) Naglazyme (galsulfase) Strensiq (asfotase alfa) precertification effective 1/14/2016 Vimizim (elosulfase alfa) VPRIV (velaglucerase alfa) Erythropoiesis-stimulating agents: Aranesp (darbepoetin alfa) Epogen (epoetin alfa) Mircera (epoetin beta) Procrit (epoetin alfa) Fusilev (levoleucovorin) Gattex (teduglutide) Gazyva (obinutuzumab) Granulocyte-colony stimulating factor drugs/medical injectables Granix (tbo-filgrastim) Leukine (sargramostim) Neulasta (pegfilgrastim) Neupogen (filgrastim) Zarxio (filgrastim-sndz)

3 Other drugs and medical injectables (continued) Growth hormone: Kadcyla (ado-trastuzumab emtansine) Rituxan (rituximab) Rebif (interferon beta-1a) Genotropin (somatropin) Perjeta (pertuzumab) Simponi (golimumab) Tecfidera (dimethyl fumarate) Humatrope (somatropin) Ilaris (canakinumab) Simponi Aria (golimumab) Tysabri (natalizumab) Increlex (mecasermin) Iplex (mecasermin rinfabate) effective 1/14/2016, precertification not required Norditropin (somatropin) Nutropin AQ (somatropin) Omnitrope (somatropin) Saizen (somatropin) Sermorelin Acetate (sermorelin acetate) Serostim (somatropin) Tev-Tropin (somatropin) Zorbtive (somatropin) Hepatitis C drugs: Daklinza (daclatasvir) Harvoni (sofosbuvir/ledipasvir) Olysio (simeprevir) Sovaldi (sofosbuvir) Technivie (ombitasvir/paritaprevir/ritonavir) Viekira Pak (paritaprevir/ritonavir/ombitasvir/ dasabuvir) Viekira Pak XR (ombitasvir/paritaprevir/ ritonavir and dasabuvir) precertification effective 8/2/2016 Zepatier (elbasvir/grazoprevir) precertification effective 2/12/2016 Hereditary angioedema agents: Berinert (C1 esterase inhibitor) Cinryze (C1 esterase inhibitor) Firazyr (icatibant acetate) Kalbitor (ecallantide) Ruconest (C1 esterase inhibitor) HER2 receptor drugs: Herceptin (trastuzumab) Imlygic (talimogene laherparepvec) precertification effective 2/12/2016 Immunoglobulins (review of drug and site of care required): Bivigam (immune globulin) Carimune NF (immune globulin) Flebogamma (immune globulin) GamaSTAN (immune globulin) Gammagard (immune globulin) Gammaked (immune globulin) Gammaplex (immune globulin) Gamunex-C (immune globulin) Hizentra (immune globulin) HyQvia (immune globulin) Octagam (immune globulin) Privigen (immune globulin) Immunologic agents: Actemra (tocilizumab) Actemra SC (tocilizumab) Amevive (alefacept) effective 1/14/2016, precertification not required Cimzia (certolizumab pegol) Cosentyx (secukinumab) Enbrel (etanercept) Entyvio (vedolizumab) Humira (adalimumab) Inflectra (infliximab-dyyb) precertification effective 6/3/2016 Kineret (anakinra) Orencia (abatacept) Otezla (apremilast) Remicade (infliximab) Stelara (ustekinumab) Taltz (ixekizumab) precertification effective 6/3/2016 Xeljanz, Xeljanz XR (tofacitinib) Injectable infertility drugs: All 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) Repronex (menotropins) Jevtana (cabazitaxel) Keytruda (pembrolizumab) Krystexxa (pegloticase) 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) Plegridy (peginterferon beta-1a) Myalept (metreleptin) Natpara (parathyroid hormone) Opdivo (nivolumab) Osteoporosis drugs: All ibandronate sodium, pamidronate disodium and zoledronic acid Aredia (pamidronate disodium) Boniva (ibandronate sodium) Forteo (teriparatide) Miacalcin (calcitonin) Prolia (denosumab) Reclast (zoledronic acid) Zometa (zoledronic acid) Pegylated interferons: Infergen (interferon alfacon-1) Intron A (interferon alfa-2b) Pegasys (peginterferon alfa-2a) PegIntron (peginterferon alfa-2b) Rebetron (ribavirin and peginterferon alfa-2b) Roferon-A (interferon alfa-2a) 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)

4 Other drugs and medical injectables (continued) Revatio (sildenafil citrate) Tracleer (bosentan) Tyvaso (treprostinil) Uptravi (selexipag) precertification effective 3/1/2016 Veletri (epoprostenol sodium) Ventavis (iloprost) Respiratory injectables (category added effective July 1, 2016): Cinqair (reslizumab) precertification effective 6/3/2016 Nucala (mepolizumab) precertification effective 1/14/2016 Xolair (omalizumab) Soliris (eculizumab) review of drug and site of care required Synagis (palivizumab) Temodar oral formulation (temozolomide) Vectibix (panitumumab) Viscosupplementation: Euflexxa, Hyalgan, Genvisc, Supartz (sodium hyaluronate) Gel-One (cross-linked hyaluronate) Gelsyn-3, Hymovis (hyaluronic acid) precertification for Hymovis required 4/15/2016 Monovisc, Orthovisc (sodium hyaluronate) Synvisc, Synvisc-One (hylan) Xeloda (capecitabine) Xgeva (denosumab) Xofigo (radium Ra 223 dichloride) Yervoy (ipilimumab) Zaltrap (ziv-aflibercept) Plan sponsor deviations Self-insured commercial plan sponsors may have different, or additional precertification requirements. Unless noted, use plan-specific online resources or call the number on the member s insurance card for more precertification information. This list (NPL) does not apply to the following plans: Alamance County Federal Employees Health Benefit Plan (Rural Carrier Benefit Plan, Mail Handlers Benefit Plan, and Foreign Service Benefit Plan) Government Employees Health Association (GEHA) Gwinnett Hospital System --Custom precertification requirements for computed tomography (CT) and magnetic resonance imaging (MRI) --Custom precertification process for gastric bypass apply Lifepoint Mercy Health (see Mercy Co-Workers Pre-Authorization List) Montana Health (MHC) CO-OP Piedmont Healthcare

5 For the following plans, also access the Coventry Health Care of Missouri website Alton IBEW-NECA Local 649 Health and Welfare Plan Automotive, Petroleum, and Allied Industries Employees Welfare Fund Local 618 Carpenters Health and Welfare Trust Fund of St. Louis City of Peoria Clean the Uniform Employers and Cement Masons Local 90 Health and Welfare Fund Employers and Laborers Locals 100 and 397 Health and Welfare Fund IBEW Local 309 Health and Welfare Fund Employers and Operating Engineers Local 520 Health and Welfare Fund Esse Health Greater St. Louis Construction Laborers Welfare Fund IBEW Local No. 1 Health and Welfare Fund Maryville University Mercy Health Co-workers Prior Authorization Guide Missouri Highways and Transportation Commission acting by and through the Board of Trustees for the Missouri Department of Transportation and Missouri State Highway Patrol Medical and Life Insurance Plan (MODOT) Plumbers & Pipefitters Local No. 101 Health & Welfare Fund Plumbers Local 360 Health & Welfare Fund Plumbers and Pipefitters Welfare Educational Fund Service Employees International Union Local 2000 Health and Welfare Fund Sheet Metal Workers Local 36 Welfare Fund Special School District of St. Louis County St. Louis Glass and Allied Industries Health and Welfare Fund Steamfitters Local 439 Health & Welfare Fund The Curators of the University of Missouri (University of MO Healthy Savings Program; University Of MO MyRetiree Health Program; University Of MO PPO Health Program) The Doe Run Resources Corporation DBA The Doe Run Company United Food and Commercial Workers Union Local 655 Welfare Fund Special programs All states National Medical Excellence Program By phone at for 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 chemo. Precertification is required for all members with a Coventry commercial or Medicare plan. Vendor managed special programs For all of the following special programs except joint, precertification is required in any place of service except inpatient, emergency room and observation bed status. When the joint program applies, precertification is also required for inpatient hospital place of service. Precertification requirements: Precertification is required for members with a fully insured Coventry commercial plan, or a Coventry Medicare plan. Precertification is generally not required for members with a self-insured Coventry commercial plan unless noted on the Plan Sponsor precertification list(s).

6 States: PA, VA, OH Medical injectables Contact ICORE dba MagellanRX By phone --For members in PA/OH: For members in VA: Online at By phone , Monday through Friday, during normal Heart catheterization and/or high-tech By phone --For members in PA/OH: For members in VA: State: GA High-tech By phone By phone , Monday through Friday, during normal

7 State: WV Heart catheterization and/or high-tech By phone at By phone , Monday through Friday, during normal business hours or as required by federal or state regulations States: DE, MD Medical injectables Contact ICORE dba MagellanRX By phone Online at By phone , Monday through Friday, during normal High-tech By phone , Monday through Friday, during normal business hours or as required by federal or state regulations State: NC Chemo By phone By fax

8 State: SC Chemo By phone By fax High-tech By phone at State: FL By phone , Monday through Friday, during normal High-tech and sleep study polysomnography By phone oncology Therapeutic oncology Hematology/ oncology (chemo) Counties: Dade, Broward, Palm Beach, Martin and St. Lucie Products: Medicare By phone By fax Cardiology Counties: Dade, Broward, Palm Beach, Martin and St. Lucie Products: Medicare By phone By fax States: NV, TX By phone , Monday through Friday, during normal Online at

9 State: LA By phone , Monday through Friday, during normal Chemo By phone By fax States: NE\IA\SD, MO\IL, KS\OK By phone , Monday through Friday, during normal By phone, Monday through Friday, during normal business hours or as required by federal or state regulations: --For members in KS/OK: For members in NE/IA/SD, MO/IL: Chemo By phone By fax Heart catheterization and/or high-tech By phone --For members in IA/SD: For members in IL: For members in KS and OK: For members in MO: For members in NE: State: UT (Altius) By phone , Monday through Friday, during normal By phone , Monday through Friday, during normal business hours or as required by federal or state regulations

10 General information 1. Precertification (i.e. prior authorization) and notification are the processes of collecting information before elective inpatient admissions and/or selected ambulatory procedures and services take place. a. Requests for precertification and notification must be received before rendering services. If the member s plan requires precertification, please submit a request to us. For elective services, it s best to contact us at least two weeks in advance. b. If you don t precertify the services listed below, Coventry, employer groups or members won t be financially responsible for the applicable service(s), if those services are still given. c. This material is provided for informational purposes only. It s not intended to direct treatment decisions. d. The level of review of individual items on this precertification list may vary from time to time at our discretion. The lack of a denial for a particular service or supply should not be interpreted as our approval for any subsequent service. e. To help you save time, it s best to submit precertification requests and inquiries online. If you need help, just call us. Look for the precertification number on the member s ID card. f. Precertification is the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company s clinical criteria for coverage. View medical and pharmacy Clinical Policy Bulletins online. g. If member eligibility and plan coverage for the procedure/service you asked for hasn t changed, precertification approvals are valid for six months in all states. This is unless we tell you otherwise when you precertify. h. Services not included on the precertification list are subject to the coverage terms of the member s plan. i. We typically update the precertification list annually in January and July. However, we may add new, U.S. Food and Drug Administration (FDA)-approved drugs, to the list at different times. j. Use directprovider.com to submit electronic authorization requests and access: Member eligibility, claims and payment information Online search options for diagnosis and procedure codes 2. In Texas, the reference to precertification means 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 does not mean a reliable representation of payment for care or services to fully insured HMO and PPO members as defined by Texas law. 3. Not all plans are offered in all service areas and not all plans include all services listed. For example, precertification programs don t apply to fully insured members in Indiana. 4. Precertification is required when Coventry is the secondary payer. 5. Precertification is required for maternity and newborn confinements that exceed the standard LOS. Standard LOS for vaginal deliveries is a total of three days or less; standard LOS for Cesarean section is a total of five days or less. 6. For precertification of oral medications not indicated on this list, call the customer service phone number indicated on the member s ID card. 7. For drugs administered orally, by injection or infusion: a. Fully insured Texas and Louisiana members continue to receive coverage for drugs added to the precertification list in accordance with their current plan benefit design until their next plan renewal date. b. Fully insured California HMO members and fully insured Connecticut PPO members receiving coverage for drugs added to the precertification list continue to have coverage. 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. Drug coverage continues for these Connecticut members as long as the drug is medically necessary and more medically beneficial than other covered drugs. c. The prescribing provider responds to requests for additional information. For fully insured members with a contract state of Colorado, precertification requests received will be approved or denied within time frames mandated by Colorado Regulation Rx Prior Authorization Aetna Inc K (8/16)