2026 precertification list – updated March 1, 2026 Form

Participating provider precertification list for Aetna® Updated May 1, 2026 This document is a quick guide for your office to use for precertification with patients enrolled in Aetna health plans. This process is also known as prior authorization or prior approval. Use this document as a resource to ensure smooth and effective collaboration with us. It will be your reference for Current Procedural Terminology (CPT®) codes for services, programs and prescriptions that require approval for coverage. See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area. Participating physicians, hospitals and other health care providers are independent contractors and are neither agents nor employees of Aetna®. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change. Out-of-network/non-contracted providers are under no obligation to treat Aetna members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. The formulary, provider and/or pharmacy network may change at any time. You will receive notice when necessary. Make sure you review and understand how to submit a precertification request to us. To learn more, refer to the How to submit section. Check out the table of contents on the next page for a closer look at what you’ll find in this guide. Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). Aetna provides certain management services on behalf of its affiliates. Banner|Aetna, Allina Health | Aetna, are affiliates of Aetna Life Insurance Company and its affiliates (Aetna). Aetna provides certain management services to these entities. CPT only Copyright 2025 American Medical Association. All Rights Reserved. 1013000-01-39 (05/26)

Table of contents How to submit General info Services Drugs Special programs Use the navigation options above to go directly to each section. You can also use Ctrl + F on Windows® (Command + F on Mac®) to search the document for keywords. Submitting precertification requests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

General information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Services that require precertification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Blood-clotting factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Other drugs and medical injectables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Special programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 This information applies to: • Aetna® plans • Aetna Medicare plans • Allina Health | Aetna plans • Banner|Aetna plans • Innovation Health® plans This information doesn’t apply to members in a Traditional Choice® plan or an indemnity plan.

3 Submitting precertification requests General info Services Drugs Special programs How to submit IMPORTANT: As the patient’s attending provider, you must complete all sections of a submission. If you don’t send all medical records we ask for, it may delay our review or cause a denial of coverage. You must submit precertification requests at least two weeks in advance. You can save time by requesting precertification online. Doing so is fast, secure and simple. You can submit most requests through our Availity® provider portal. You can also send requests for specialty drugs with Novologix® through Availity. Go to Availity.com to start a request. Note: Your office may also send in an electronic request. Just use your own Electronic Medical Record (EMR) system. Go to Aetna.com/PrecertificationOverview to learn more about the precertification process. What happens next Once we have the requested information, we’ll perform a clinical review. We’ll let you know when we make a coverage determination. How we make coverage determinations If you’re asking for precertification for a Medicare Advantage member, we use the Centers for Medicare & Medicaid service (CMS) benefit policies to make our coverage decisions. This includes national coverage determinations (NCDs) and local coverage determinations (LCDs), when available. If there isn’t an available NCD or LCD to review, we’ll use the Aetna Medicare Part B Drug Criteria, Clinical Policy Bulletins and Precertification List. You can find them by going to the website listed on the back of the member’s ID card. Questions? If you have any questions about submitting a request or about our precertification process, call us: • Commercial plans: 1-888-632-3862 (TTY: 711) • Medicare plans: 1-800-624-0756 (TTY: 711) Or visit Aetna.com/ProviderPrecertificationList to learn more.

4 General information Services Drugs Special programs How to submit General info You should know • This material is for your information only. It’s not meant to direct treatment decisions. • The review of items on this list may vary at our discretion. If you receive approval for a service or supply, it’s for that service or supply only. • Services that don’t need precertification are subject to the coverage terms of the member’s plan. • We require precertification when we’re the primary or secondary payer. Coverage changes and updates • If member eligibility and plan coverage for the procedure or service you asked for hasn’t changed, precertification approvals are valid for six months. This is true for all states. This is also the case unless we tell you otherwise when you receive the precertification decision. • We update the precertification list each year. We usually do this in January and July. But we may add new drugs approved by the Federal Drug Administration (FDA) to the list at other times. For more information • 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 can assess if a caller is making an inquiry or asking for a coverage decision or organization determination. • We don’t offer all plans in all service areas. Not all plans include all services listed. For example, precertification programs don’t apply to fully insured members in Indiana.

5 Services Drugs Special programs How to submit General information (continued) General info Behavioral health • Refer to the behavioral health precertification list for a list of behavioral health services that require precertification. Emergency services Emergency services don’t require precertification except when one of the following apply: • Procedures requiring precertification don’t occur on the same day as the emergency room visit • Emergency visit resulting in an inpatient hospital admission requires reporting within two business days of the admission Federal Employee Health Benefit Plans information Precertification is not required for MHBP, the Rural Carrier Benefit Plan, and the Foreign Service Benefit Plan when original Medicare is the primary payer. Precertification is required for the Aetna Medicare Advantage Plan for MHBP Standard Option, Aetna Medicare Advantage for Rural Carrier Benefit Plan, and the Foreign Service Benefit Plan – Aetna Medicare Advantage Plan. Innovation Health® • 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 Innovation Health. • Find more information about notification and coverage determinations. • We require precertification when Aetna or Innovation Health is the secondary payer. Maternity information We require precertification for maternity and newborn stays that are more than the standard length of stay (LOS). Standard LOS for: • Vaginal deliveries are three days or fewer • Cesarean section is five days or fewer Oral medications and injections Contact Aetna® Pharmacy Management for precertification of oral medications not on this list. • Their number is 1-800-414-2386 (TTY: 711). • Call 1-866-782-2779 (TTY: 711) for information on injectable medications not listed. For drugs administered orally, by injection or infusion: • Drugs newly approved by the FDA may require precertification review. • Members of fully insured Texas and Louisiana plans have coverage for drugs we add to the precertification list according to their current plan design until their plan renews. • Fully insured California HMO members and fully insured Connecticut PPO members covered for drugs added to the precertification list continue to have coverage.

6 General information (continued) Services Drugs Special programs How to submit General info

• Drug coverage continues for these California members as long as their doctor prescribes it appropriately. It must also be a 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.
• 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. Student Health and Allina Health | Aetna plan information For members enrolled in Aetna Student HealthSM or Allina Health | Aetna, precertification isn’t required for the following outpatient services: • Diagnostic cardiology • Hip and knee arthroplasties • Home health care • Pain management • Peripheral arterial disease (PVD) • Polysomnography • Radiology imaging • Radiation oncology Special information for members enrolled in a Dual Special Needs Plan (D-SNP) in Florida Precertification may be required for Medicaid
  services to eligible recipients. You can use your current electronic solutions to submit a precertification request, or call the number listed on the member’s ID card.
  Texas members • 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.

7 Drugs Special programs How to submit General info Services Services that require precertification For more information, read all general precertification guidelines. For Commercial members, certain elective procedures, as noted with an asterisk (*), are subject to the medical necessity review of the procedure and the site of service. Procedure name/description CPT codes

1. Inpatient confinements, including hospital at home (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 “Maternity information” in the General information section.) Note: Prior authorizations for skilled nursing or rehabilitation facility stays for Medicare Advantage members in New Jersey, New York, Pennsylvania and West Virginia are handled by EviCore Healthcare.
2. Ambulance Precertification required for transportation by fixed-wing aircraft (plane) A0140, A0430, A0435, A0999, T2004, T2007, S9960
3. Arthroplasty • Total ankle 27702
4. Arthroscopic hip surgery to repair impingement syndrome, including labral repair* 29914, 29915, 29916, 29860, 29861, 29862, 29863
5. Autologous chondrocyte implantation* 27412, J7330, S2112
6. Cardiology • Implantable loop recorder 33285 • Watchman™ 33340 • Electrophysiological (EP) study 93653, 93654, 93656
7. Chiari malformation decompression surgery 61343 *For Commercial members, this elective procedure is subject to the medical necessity review of the procedure and the site of service.

8 General info Drugs Special programs How to submit Services Procedure name/description CPT codes

8. Cochlear device and/or implantation* 69930, L8614, L8619
9. 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
10. Dental implants 21245, 21246, 21248, 21249
11. Dialysis visits When a participating provider starts a request and dialysis is to be performed at a nonparticipating facility 90935, 90937, 90999
12. Dorsal column (lumbar) neurostimulators: trial or implantation 63650, 63655, 63663, 63664, 63685, 63688
13. Electric or motorized wheelchairs E0983, E0984, E1007 K0010, K0011, K0012, K0013, K0014, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898, K0899 Services that require precertification (continued) *For Commercial members, this elective procedure is subject to the medical necessity review of the procedure and the site of service.

9 General info Drugs Special programs How to submit Services Procedure name/description CPT codes

14. Endoscopic nasal balloon dilation procedures* 31295, 31296, 31297, 31298
15. Functional endoscopic sinus surgery (FESS)* 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276, 31287, 31288
16. Gender affirmation surgery 55970, 55980, 56805, 57335 11950, 11951, 11952, 11954, 15771, 15772, 15775, 15776, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15824, 15825, 15826, 15828, 17380, 19318, 21270, 30400, 30410, 30420, 30430, 30435, 30450, 53430, 54125, 54400, 54401, 54405, 54406, 54408, 54410, 54411, 54415, 54416, 54417, 54520, 54660, 54690, 55175, 55180, 56625, 56800, 56810, 57106, 57107, 57110, 57111, 57291, 57292, 58150, 58180, 58260, 58262, 58275, 58280, 58285, 58290, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58661, 58720
17. Hip osteotomy 27146, S2115
18. Hyperthermic intraperitoneal chemotherapy (HIPEC) 96547, 96548
19. Hyperbaric oxygen therapy G0277, 99183 — precertification required for Commercial members only
20. Infertility services and pre-implantation genetic testing 58970, 58974, 58976, 76948, 89250, 89251, 89253, 89254, 89255, 89257, 89258, 89264, 89268, 89272, 89280, 89281, 89290, 89291, 89337, 89342, 89346 S4011, S4013, S4014, S4015, S4016, S4017, S4018, S4020, S4021, S4022, S4023, S4025, S4035 Services that require precertification (continued) *For Commercial members, this elective procedure is subject to the medical necessity review of the procedure and the site of service.

10 General info Drugs Special programs How to submit Services Procedure name/description CPT codes

21. Knee arthroscopy 29875, 29876, 29877, 29879 — precertification required for Medicare Advantage members only
22. Knee meniscectomy 29880, 29881, 29882, 29883 — precertification required for Medicare Advantage members only
23. Lower limb prosthetics, such as microprocessor- controlled lower limb prosthetics L5781, L5782, L5856, L5857, L5858, L5859, L5926, L5968, L5969, L5973, L5980, L5987, L5999
24. Neurostimulator implantation 64553, 64555, 64561, 64568, 64569, 64575, 64580, 64581, 64582, 64583, 64584, 64585, 64590, 64595
25. Nonparticipating freestanding ambulatory surgical facility services, when referred by a participating provider
26. Orthognathic surgery procedures, bone grafts, osteotomies and surgical management of the temporomandibular joint 21010, 21050, 21060, 21070, 21073, 21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21159, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21215, 21240, 21242, 21243, 21244, 21247, 21255, 21480, 21485, 21490, 21497, 29800, 29804
27. Osseointegrated implant* 69714, 69716 L8690, L8691, L8692, L8693
28. Osteochondral allograft/knee* 27415
29. Private duty nursing S9123, S9124, T1000, T1030, T1031
30. Prostate surgery • High intensity-focused ultrasound (HIFU) 55880
31. Proton beam radiotherapy 77520, 77522, 77523, 77525 Also see Special programs: Radiation oncology Services that require precertification (continued) *For Commercial members, this elective procedure is subject to the medical necessity review of the procedure and the site of service.

11 General info Drugs Special programs How to submit Services Procedure name/description CPT codes

32. Reconstructive or other procedures that may be considered cosmetic: • Blepharoplasty 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908 • Breast reconstruction/breast enlargement 19355, 19340, 19342, 19350, 19357, 19364, 19370, 19371, 19380, 19396, S2066, S2067, S2068
33. Reconstructive or other procedures that may be considered cosmetic (continued): • Breast reduction/mammoplasty 19316, 19318, 19325, 19328, 19330 • Excision of excessive skin due to weight loss 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847 • Gastroplasty/gastric bypass 43631, 43632, 43633, 43634, 43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 43999, 49999 • Lipectomy or excess fat removal 15876, 15877, 15878, 15879 • Surgery for varicose veins, except stab phlebectomy 36475, 36476, 36478, 36479, 37700, 37718, 37722, 37735, 37760, 37761, 37780, 37785, 0524T
34. Shoulder arthroplasty, including revision procedures 23470, 23472, 23473,* 23474
35. Site of service For Commercial members only, see Special programs for more information. Services that require precertification (continued) *For Commercial members, this elective procedure is subject to the medical necessity review of the procedure and the site of service.

12 General info Drugs Special programs How to submit Services Procedure name/description CPT codes

36. Spinal procedures: • Artificial intervertebral disc surgery (cervical spine) 22856, 22858, 22861
    • Artificial intervertebral disc surgery (lumbar spine) 22857, 22860, 22862, 22865 • Cervical laminoplasty 63050, 63051 • Cervical, lumbar and thoracic laminectomy and/or laminotomy procedures 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63052, 63053, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63200, 63265, 63266, 63267 • Kyphectomy 22818, 22819 • Laminectomy with rhizotomy 63185, 63190 • Removal of spinal instrumentation
    22850, 22852, 22855 Services that require precertification (continued) For Commercial members, this elective procedure is subject to the medical necessity review of the procedure and the site of service.

13 General info Drugs Special programs How to submit Services Procedure name/description CPT codes

36. Spinal procedures (continued): • Spinal fusion surgery C1821, 22102, 22103, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22830, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22853, 22854, 22859, 27278, 27279, 27280 • Surgery for spine deformity 22800, 22802, 22804, 22808, 22810, 22812 • Precertification required for Commercial plans only for the following: 22836,22837, 22838, 0656T, 0657T, 0790T • Vertebral corpectomy 63081, 63082, 63085, 63086, 63090, 63091 • Vertebroplasty/kyphoplasty 22510, 22511, 22512, 22513, 22514, 22515
37. Stimulators • Electrical stimulation device used for cancer treatment E0766
38. Urology • Artificial urinary sphincter 53445
39. Uvulopalatopharyngoplasty, including laser-assisted procedures* 42145, 42140, 42299, S2080
40. Ventricular assist devices 33975, 33978, 33979, 33981, 33990, 33991, 33992, 33993, 92970
41. Whole exome sequencing 81415, 81416, 81417 Services that require precertification (continued) *For Commercial members, this elective procedure is subject to the medical necessity review of the procedure and the site of service.

14 General info Drugs Special programs How to submit Services Procedure name/description CPT codes

42. Whole genome sequencing 81425, 81426, 81427 0094U, 0214U, 0215U, 0335U, 0336U, 0425U, 0426U Services that require precertification (continued)

15 Blood-clotting factors How to submit General info Services Drugs Special programs Blood-clotting factors (precertification for outpatient infusion of this drug class is required) • When the member is enrolled in a Commercial plan, you can call 1-866-752-7021 (TTY: 711) for precertification • When the member is enrolled in a Medicare Advantage plan, you can call 1-866-503-0857 (TTY: 711) for precertification or fax request forms to 1-844-268-7263 (TTY: 711).

• See our Medicare online resources for more about preferred products or to find a precertification fax form
• Site of care doesn’t apply to Medicare Part B drugs Drug name Description Advate (J7192) antihemophilic factor, human recombinant Adynovate (J7207) antihemophilic factor [recombinant], PEGylated Afstyla (J7210) antihemophilic factor [recombinant], single chain Alphanate (J7186) antihemophilic factor/von Willebrand factor complex [human] AlphaNine SD (J7193) coagulation factor IX [human] Alprolix (J7201) coagulation factor IX [recombinant], Fc fusion protein Altuviiio (J7214) antihemophilic factor [recombinant], Fc fusion protein BeneFix (J7195) coagulation factor IX [recombinant] Beqvez (J1414) (fidanacogene elaparvovec-dzkt) — precertification required for the drug and site of care Commercial plans call 1-866-752-7021 (TTY: 711) Medicare Advantage plans call 1-866-503-0857 (TTY: 711) Coagadex (J7175) coagulation factor X [human] Corifact (J7180) factor XIII concentrate [human] Eloctate (J7205) antihemophilic factor [recombinant], Fc fusion protein Esperoct (J7204) antihemophilic factor [recombinant], glycopegylated-exei Factor XIII (J7191) Factor viii (antihemophilic factor (porcine))

16 General info Services Special programs How to submit Drugs Blood-clotting factors Drug name Description FEIBA, FEIBA NF (J7198) anti-inhibitor coagulant complex Fibryga (J7177) fibrinogen, human Hemgenix (J1411) etranacogene dezaparvovec — precertification required for the drug and site of care Commercial plans call 1-866-752-7021 (TTY: 711) Medicare Advantage plans call 1-866-503-0857 (TTY: 711) Hemlibra (J7170) emicizumab Hemofil M (J7190) antihemophilic factor [human] Hemophilia clotting factor (J7199) not otherwise classified Humate-P (J7187) antihemophilic factor/von Willebrand factor complex [human] Idelvion (J7202) antihemophilic factor [recombinant] Ixinity
(J7195, J7213) coagulation factor IX [recombinant] Jivi (J7208) antihemophilic factor [recombinant], PEGylated-aucl Kogenate FS (J7192) antihemophilic factor [recombinant] Kovaltry (J7211) antihemophilic factor [recombinant] NovoEight (J7182) antihemophilic factor [recombinant] NovoSeven RT (J7189) coagulation factor VIIa [recombinant] Nuwiq (J7209) simoctocog alfa Obizur (J7188) antihemophilic factor [recombinant], porcine sequence Profilnine (J7194) factor IX complex Rebinyn (J7203) coagulation factor IX [recombinant], glycoPEGylated Blood-clotting factors (continued)

17 General info Services Special programs How to submit Drugs Drug name Description Recombinate (J7192) antihemophilic factor [recombinant] RiaSTAP (J7178) fibrinogen concentrate [human] Rixubis (J7200) coagulation factor IX [recombinant] Roctavian (J1412) valoctocogene roxaparvovec-rvox — precertification required for the drug and site of care Commercial plans call 1-866-752-7021 (TTY: 711) Medicare Advantage plans call 1-866-503-0857 (TTY: 711) Sevenfact (J7212) coagulation factor VIIa [recombinant]-jncw Tretten (J7181) coagulation factor XIII a-subunit [recombinant] Vonvendi (J7179) von Willebrand factor [recombinant] Wilate (J7183) von Willebrand factor/coagulation factor VIII complex [human] Xyntha, Xyntha Solofuse (J7185) antihemophilic factor [recombinant] Blood-clotting factors Blood-clotting factors (continued)

18 General info Services Special programs How to submit Drugs Other drugs and medical injectables For the following services, when the member is enrolled in a Commercial plan, you can call 1-866-752-7021 (TTY: 711) for precertification or fax request forms to 1-888-267-3277 (TTY: 711). However, the following exceptions apply: • For precertification of pharmacy-covered specialty drugs (noted with *) when the member is enrolled in a Commercial plan, call 1-855-240-0535 (TTY: 711). Or fax applicable request forms to 1-877-269-9916 (TTY: 711). • You can use the drug-specific Specialty Medication Request Form located online under “Specialty Pharmacy Precertification.” • You can submit Specialty Pharmacy precertification requests electronically using provider online tools and resources on our provider portal with Availity. When the member is enrolled in a Medicare Advantage plan, you can call 1-866-503-0857 (TTY: 711) for precertification or fax request forms to 1-844-268-7263 (TTY: 711). • See our Medicare online resources for more about preferred products or to find a precertification fax form. • Site of care doesn’t apply to Medicare Part B drugs Drug name/description Abraxane (paclitaxel protein-bound particles, J9264) — precertification required for Medicare Advantage members only Acthar Gel/H. P. Acthar (corticotropin, J0801, J0802) Adakveo (crizanlizumab-tmca, J0791) — precertification required for the drug and site of care Adcetris (brentuximab vedotin, J9042) — precertification required for drug and site of care Adstiladrin (nadofaragene firadenovec-vncg, J9029) Alpha 1-proteinase inhibitor (human) (precertification required for the drug and site of care): Aralast NP (alpha 1-proteinase inhibitor, J0256) Glassia (alpha 1-proteinase inhibitor, J0257) Alpha 1-proteinase inhibitor (human) (continued): Prolastin-C (alpha 1-proteinase inhibitor, J0256) Zemaira (alpha 1-proteinase inhibitor, J0256) Alymsys (bevacizumab, Q5126) — precertification required for the drug and site of care for oncology indications only Alzheimer’s disease (precertification required for the drug and site of care): Kisunla (donanemab-azbt, J0175) Leqembi IV (lecanemab-irmb, J0174) Leqembi SQ (lecanemab-irmb, J3490 J3590
C9399) — precertification required for Medicare Advantage members only

Other drugs and medical injectables (continued) 19 General info Services Special programs How to submit Drugs Amtagvi (lifileucel, J3490, J3590, C9399, J9999) — precertification required for the drug and site of care Contact National Medical Excellence at 1-877-212-8811 (TTY: 711) Amyotrophic lateral sclerosis (ALS) drugs: (precertification required for the drug and site of care): Qalsody (tofersen, J1304) Radicava (edaravone, J1301) Anktiva (nogapendekin alfa inbakicept-pmln, J9028) Autoimmune infused infliximab: (precertification required for the drug and site of care): Avsola (infliximab-axxq, Q5121) Inflectra (infliximab-dyyb, Q5103) Remicade (infliximab, J1745) Renflexis (infliximab-abda, Q5104) Avastin (bevacizumab, J9035) — precertification required for the drug and site of care for oncology indications only Aveed (testosterone undecanoate, J3145) Axtle (pemetrexed, avyxa J9292) — precertification required for Medicare Advantage members only Avzivi (bevacizumab-tnjn, J3490, J3590, C9399, J9999) Beizray (docetaxel, J9174)— precertification required for Medicare Advantage members only Belrapzo (bendamustine HCl, J9036) Bendeka (bendamustine HCl, J9034) Benlysta (belimumab, J0490) — precertification required for the drug and site of care Besponsa (inotuzumab ozogamicin, J9229) Bizengri (zenocutuzumab-zbco, J9382) Bortezomib (J9046, J9048, J9049, J9051)
Commercial plans — precertification required for multiple myeloma only Medicare plans — precertification required for all diagnoses Boruzu (bortezomib, J9054) Commercial plans — precertification required for multiple myeloma only Medicare plans — precertification required for all diagnoses Botulinum toxins: Botox (onabotulinumtoxinA, J0585)— precertification required for Commercial members only Daxxify (daxibotulinumtoxin A, J0589) Dysport (abobotulinumtoxinA, J0586) Letybo (letibotulinumtoxinA-wlbg, J3490, J3590, C9399) Myobloc (rimabotulinumtoxinB, J0587) Xeomin (incobotulinumtoxinA, J0588)— precertification required for Commercial members only *For precertification when the member is enrolled in a Commercial plan, call 1-855-240-0535 (TTY: 711). Or fax applicable request forms to 1-877-269-9916 (TTY: 711).

20 General info Services Special programs How to submit Drugs Cabenuva (cabotegravir; rilpivirine, J0741)— precertification required for drug and site of care
effective April 1, 2026 Cablivi (caplacizumab-yhdp, C9047) Calcitonin gene-related peptide (CGRP) receptor inhibitors: Vyepti (eptinezumab-jjmr, J3032) — precertification required for the drug and site of care Cardiovascular — PCSK9 inhibitors: Leqvio (inclisiran, J1306) Casgevy (exagamglogene autotemcel, J3392) — precertification required for the drug and site of care Contact National Medical Excellence at 1-877-212-8811 (TTY: 711) Chimeric Antigen Receptor T-Cell Therapy (CAR-T) — contact National Medical Excellence at 1-877-212-8811 (TTY: 711) Abecma (idecabtagene vicleucel, Q2055) Aucatzyl (obecabtagene autoleucel, obe-cel, Q2058) Breyanzi (lisocabtagene maraleucel, Q2054) Carvykti (ciltacabtagene autoleucel, Q2056) Kymriah (tisagenlecleucel, Q2042) Tecartus (brexucabtagene autoleucel, Q2053) Yescarta (axicabtagene ciloleucel, Q2041) Columvi (glofitamab-gxbm, J9286) Complement inhibitor drugs: (precertification required for the drug and site of care): Piasky (crovalimab-akkz, J1307) Veopoz (pozelimab-bbfg, J9376) Cortrophin Gel (repository corticotropin, J3490, J3590) Cosela (Trilaciclib, J1448 Crysvita (burosumab-twza, J0584) — precertification required for the drug and site of care Cyramza (ramucirumab, J9308) Danyelza (naxitamab-gqgk, J9348) Darzalex (daratumumab, J9145) Darzalex Faspro (daratumumab and hyaluronidase-fihj, J9144) Datroway (datopotamab deruxtecan-dlnk, J9011) — precertification required for the drug and site of care Docivyx (docetaxel, J9172)- precertification required for Medicare Advantage members only Elahere (mirvetuximab soravtansine-gynx, J9063) Elrexfio (elranatamab-bcmm, J1323) Empliciti (elotuzumab, J9176) Emrelis (telisotuzumab vedotin-tllv, J9326) Other drugs and medical injectables (continued) For precertification when the member is enrolled in a Commercial plan, call 1-855-240-0535 (TTY: 711). Or fax applicable request forms to 1-877-269-9916 (TTY: 711).

21 General info Services Special programs How to submit Drugs Enjaymo (Sutimlimab-jome, J1302) — precertification required for the drug and site of care Enzyme replacement drugs: Adzynma (ADAMTS13, recombinant-krhn, J7171) — precertification required for the drug and site of care Aldurazyme (laronidase, J1931) — precertification required for the drug and site of care Avlayah (tividenofusp alfa-eknm, J3490, J3590, C9399)— precertification required effective May 1, 2026 Brineura (cerliponase alfa, J0567) Cerezyme (imiglucerase, J1786) — precertification required for the drug and site of care Elaprase (idursulfase, J1743) — precertification required for the drug and site of care Elelyso (taliglucerase alfa, J3060) — precertification required for the drug and site of care Elfabrio (pegunigalsidase alfa-iwxj, J2508) — precertification required for the drug and site of care Fabrazyme (agalsidase beta, J0180) — precertification required for the drug and site of care Kanuma (sebelipase alfa, J2840) — precertification required for the drug and site of care Lamzede (velmanase alfa, J0217) Loargys (pegzilarginase, J3490, J3590, C9399)— precertification required for the drug and site of care effective April 1, 2026 Lumizyme (alglucosidase alfa, J0220, J0221) — precertification required for the drug and site of care Enzyme replacement drugs (continued): Mepsevii (vestronidase alfa-vjbk, J3397) — precertification required for the drug and site of care Naglazyme (galsulfase, J1458) — precertification required for the drug and site of care Nexviazyme (avalglucosidase alfa-ngpt, J0219) — precertification required for the drug and site of care Pombiliti (cipaglucosidase alfa-atga, J1203) Strensiq (asfotase alfa, J3490, J3590) Vimizim (elosulfase alfa, J1322) — precertification required for the drug and site of care VPRIV (velaglucerase alfa, J3385) — precertification required for the drug and site of care Xenpozyme (olipudase alfa-rpcp, J0218) — precertification required for the drug and site of care Epkinly (epcoritamab-bysp, J9321) Erbitux (cetuximab, J9055) Erythropoiesis-stimulating agents: Aranesp (darbepoetin alfa, J0881, J0882) — precertification required for Commercial members only Epogen (epoetin alfa, J0885, Q4081) Mircera (methoxy polyethylene glycol-epoetin beta, J0887, J0888) — precertification required for Commercial members only Procrit (epoetin alfa, J0885, Q4081)— precertification required for Commercial members only Other drugs and medical injectables (continued) For precertification when the member is enrolled in a Commercial plan, call 1-855-240-0535 (TTY: 711). Or fax applicable request forms to 1-877-269-9916 (TTY: 711).

General info How to submit 22 Services Special programs Drugs Retacrit (recombinant human erythropoietin-epbx, Q5105, Q5106) Evkeeza (evinacumab-dgnb, J1305) — precertification required for the drug and site of care Fusilev (levoleucovorin, J0641) Fyarro (sirolimus protein-bound particles for injectable suspension, J9331) Gattex (teduglutidem, J3490) Givlaari (givosiran, J0223) — precertification required for the drug and site of care Granulocyte-colony stimulating factors: Armlupeg (pegfilgrastim-unne C9399, J3590) — precertification required effective April 1, 2026 Filkri (filgrastim-laha J3490 J3590 C9399)— precertification required effective May 1, 2026 Fulphila (pegfilgrastim-jmdb, Q5108)— precertification required for commercial only effective May 1, 2026 Fylnetra (pegfilgrastim-pbbk, Q5130) Granix (tbo-filgrastim, J1447) Leukine (sargramostim, J2820) Neulasta (pegfilgrastim, J2506) — precertification required for Commercial members only Neupogen (filgrastim, J1442) Nivestym (filgrastim-aafi, Q5110) Nypozi (filgrastim-txid, Q5148) Nyvepria (pegfilgrastim-apgf, Q5122) Releuko (filgrastim-ayow, Q5125) Granulocyte-colony stimulating factors continued): ( Rolvedon (eflapegrastim-xnst, J1449) Ryzneuta (efbemalenograstim alfa-vuxw, J9361) Stimufend (pegfilgrastim-fpgk, Q5127) Udenyca (pegfilgrastim-cbvq, Q5111) Udenyca OBI (pegfilgrastim-cbqv, Q5111) Zarxio (filgrastim-sndz, Q5101) — precertification required for Commercial members only Ziextenzo (pegfilgrastim-bmez, Q5120) Growth hormone: Skytrofa (lonapegsomatropin-tcgd, J3490, J3590) — precertification required for Medicare Advantage members only Hereditary angioedema agents: Berinert (C1 esterase inhibitor, J0597) Cinryze (C1 esterase inhibitor, J0598) — precertification required for the drug and site of care required Dawnzera (Donidalorsen Sodium, J3490 J3590
C9399) Firazyr SC (icatibant acetate, J1744)— precertification required for Commercial members only Haegarda (C1 esterase inhibitor subcutaneous [human], J0599) — precertification required for Commercial members only Kalbitor (ecallantide, J1290) Ruconest (C1 esterase inhibitor, J0596) Sajazir SC (icatibant acetate, J1744)— precertification required for Commercial members only Takhzyro (lanadelumab-flyo, J0593) Other drugs and medical injectables (continued) For precertification when the member is enrolled in a Commercial plan, call 1-855-240-0535 (TTY: 711). Or fax applicable request forms to 1-877-269-9916 (TTY: 711).

23 General info Services Special programs How to submit Drugs Hereditary transthyretin-mediated amyloidosis (ATTR) drugs: Amvuttra (vutrisiran, J0225) — precertification required for the drug and site of care Onpattro (patisiran, J0222) — precertification required for the drug and site of care Tegsedi (inotersen, J3490, J3590, C9399) Wainua (eplontersen, J3490, J3590, C9399) HER2 receptor drugs: Enhertu (fam-trastuzumab deruxtecan-nxki, J9358) Herceptin (trastuzumab, J9355) — precertification required for the drug and site of care Herceptin Hylecta (trastuzumab and hyaluronidase-oysk, J9356) Hercessi (trastuzumab-strf, Q5146) — precertification required for the drug and site of care Herzuma (trastuzumab-pkrb, Q5113) — precertification required for the drug and site of care Kadcyla (ado-trastuzumab emtansine, J9354) — precertification required for the drug and site of care Kanjinti (trastuzumab-anns, Q5117) — precertification required for the drug and site of care Margenza (margetuximab-cmkb, J9353) Ogivri (trastuzumab-dkst, Q5114) — precertification required for the drug and site of care Ontruzant (trastuzumab-dttb, Q5112) — precertification required for the drug and site of care HER2 receptor drugs (continued): Perjeta (pertuzumab, J9306) — precertification required for the drug and site of care Phesgo (pertuzumab/trastuzumab/ hyaluronidase-zzxf, J9316) Poherdy (pertuzumab-dpzb, J3490, J3590, J9999)— precertification required for drug and site of care effective April 1, 2026 Trazimera (trastuzumab-qyyp, Q5116) — precertification required for the drug and site of care Ziihera (zanidatamab-hrii, J9276) Hypoxia-inducible factor prolyl hydroxylase (HIF PH) inhibitors: Vafseo (vadadustat, J0901) — precertification required for Medicare Advantage members only Ilaris (canakinumab, J0638)— precertification required for drug and site of care effective April 1,

2026. Imdelltra (tarlatamab-dlle, J9026) Imlygic (talimogene laherparepvec, J9325) Imjudo (tremelimumab, J9347) Immunoglobulins (precertification required for the drug and site of care): Alyglo (immune globulin intravenous, human- stwk, J1552) Asceniv (immune globulin, J1554) Bivigam (immune globulin, J1556) Cutaquig (immune globulin, J1551) Other drugs and medical injectables (continued) *For precertification when the member is enrolled in a Commercial plan, call 1-855-240-0535 (TTY: 711). Or fax applicable request forms to 1-877-269-9916 (TTY: 711).

24 General info Services Special programs How to submit Drugs Cuvitru (immune globulin SC [human], J1555) Flebogamma/flebogamma dif (immune globlin, J1572)— precertification required effective March 1, 2026 GamaSTAN (immune globulin, J1460, J1559, J1560) Gammagard (immune globulin, J1569) Gammagard ERC (immune globlin, J3490,J3590,C9399)— precertification required effective March 1, 2026 Gammagard S/D (immune globulin, J1566) Gammaked (immune globulin, J1561) Gammaplex (immune globulin, J1557) Gamunex-C (immune globulin, J1561) Hizentra (immune globulin, J1559) HyQvia (immune globulin, J1575) Octagam (immune globulin, J1568) Panzyga (immune globulin, J1576) Privigen (immune globulin, J1459) Xembify (immune globulin, J1558) Yimmugo (immune globulin intravenous,
human – dira, J1553 Immunologic agents: Actemra IV (tocilizumab, J3262) — precertification required for the drug and site of care
Avtozma (tocilizumab-anoh, Q5156) — precertification required for the drug and site of care Cimzia (certolizumab pegol, J0717) Cosentyx IV (secukinumab, J3247) Enspryng (satralizumab, J3490, J3590) — precertification required for Medicare Advantage members only
Entyvio (vedolizumab, J3380) — precertification required for the drug and site of care Ilumya (tildrakizumab, J3245) Immunologic agents (continued): Imaavy (nipocalimab-aahu J9256) — precertification required for the drug and site of care Imuldosa (ustekinumab-srlf, Q5098) Omvoh (mirikizumab-mrkz, J2267)
Orencia SQ (abatacept, J0129) — precertification required for Medicare Advantage members only Orencia IV (abatacept, J0129) — precertification required for the drug and site of care Otulfi SQ/IV (ustekinumab-aauz, Q9999) Papzimeos (zopapogene imadenovec-drba J3404) — precertification required for the drug effective May 1, 2026 Pyzchiva IV (ustekinumab-ttwe, Q9997 ) Pyzchiva SC (ustekinumab-ttwe, Q9996) — precertification required for commercial members only Riabni (rituximab-arrx, Q5123) — precertification required for the drug and site of care Rituxan (rituximab, J9312) — precertification required for the drug and site of care Rituxan Hycela (rituximab/hyaluronidase human, J9311) Ruxience (rituximab-pvvr, Q5119) — precertification required for the drug and site of care Rystiggo (rozanolixizumab-noli, J3490, J3590, C9399) Selarsdi (ustekinumab-aekn, Q9998) Simponi Aria (golimumab, J1602) — precertification required for the drug and site of care Skyrizi IV (risankizumab-rzaa, J2327) Other drugs and medical injectables (continued) For precertification when the member is enrolled in a Commercial plan, call 1-855-240-0535 (TTY: 711). Or fax applicable request forms to 1-877-269-9916 (TTY: 711).

25 General info Services Special programs How to submit Drugs Spevigo (spesolimab-sbzo, J1747) — precertification required for drug and site of care effective April 1, 2026 Starjemza (ustekinumab-hmny, J3490, J3590, C9399) Stelara SC(ustekinumab, J3357) — precertification required for Commercial members only Stelara IV (ustekinumab, J3358) Steqeyma (ustekinumab-stba, Q5099) Tofidence (tocilizumab-bavi, Q5133) Tremfya IV (guselkumab, J1628) Truxima (rituximab-abbs, Q5115) — precertification required for the drug and site of care Tyenne (tocilizumab-aazg, Q5135, J3490, J3590, C9399) —precertification required for drug and site of care ustekinumab (J3490, J3590, C9399) ustekinumab-aauz (J3490, J3590, C9399)
ustekinumab-aekn (J3490, J3590, C9399) ustekinumab-stba (J3490, J3590, C9399) ustekinumab-ttwe (J3490, J3590, C9399) Vyvgart (efgartigimod alfa-fcab, J9332) Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc, J9334) — precertification required for the drug and site of care. Site of care is only required for Chronic Inflammatory Demyelinating Polyneuropathy ( CIDP) Wezlana IV (ustekinumab-auub, Q5138) Wezlana SC (ustekinumab-auub, Q5137) Yesintek (ustekinumab-kfce, Q5100) Injectable infertility drugs: Chorionic gonadotropin (J0725) Cetrotide (cetrorelix acetate, J3490, J3590) Follistim AQ (follitropin beta, S0128) Ganirelix AC (ganirelix acetate, S0132) Gonal-f (follitropin alfa, S0126) Gonal-f RFF (follitropin alfa, S0126) Menopur (menotropins, S0122) Novarel (chorionic gonadotropin, J0725) Ovidrel (choriogonadotropin alfa, J0725) Pregnyl (chorionic gonadotropin, J0725) Iron replacement agents: Feraheme (ferumoxytol, Q0138, Q0139) Injectafer (ferric carboxymaltose injection, J1439) Monoferric (ferric derisomaltose, J1437) Itvisma (onasemnogene abeparvovec-brve, C9309) — precertification required for the drug and site of care effective April 1, 2026 Jelmyto (mitomycin, J9281) Jobevne (bevacizumab-nwgd, Q5160) Kebilidi (eladocagene exuparvovec-tneq, J3490, J3590, C9399) — precertification required for the drug and site of care Khapzory (levoleucovorin, J0642) Kimmtrak (tebentafusp-tebn, J9274) Korsuva (difelikefalin, J0879) — precertification required for Commercial members only Other drugs and medical injectables (continued) *For precertification when the member is enrolled in a Commercial plan, call 1-855-240-0535 (TTY: 711). Or fax applicable request forms to 1-877-269-9916 (TTY: 711).

26 General info Services Special programs How to submit Drugs Krystexxa (pegloticase, J2507) — precertification required for the drug and site of care Kyprolis (carfilzomib, J9047) Commercial plans — precertification required for multiple myeloma only Medicare plans — precertificatoin required for all diagnoses Kyxata (Carboplatin, J9278 )— precertification required for Medicare only effective April 1, 2026 Lantidra (donislecel-jujn, J3490, J3590, C9399) Contact National Medical Excellence at 1-877-212-8811 (TTY: 711) Lenmeldy (atidarsagene autotemcel, J3391) — precertification required for the drug and site of care Contact National Medical Excellence at 1-877-212-8811 (TTY: 711) Lunsumio (mosunetuzumab, J9350) Lunsumio Velo (mosunetuzumab-axgb, C9399, J9999)— precertification required effective April 1, 2026 Luteinizing hormone-releasing hormone (LHRH) agents: Commercial plans — precertification required for prostate cancer only Medicare plans — precertificatoin required for all diagnoses Camcevi (leuprolide mesylate, J1952) Luteinizing hormone-releasing hormone (LHRH) agents (continued): Eligard (leuprolide acetate, J9217) — precertification required for Commercial members only Firmagon (degarelix, J9155) — precertification required for Commercial members only Lupron depot (leuprolide acetate, J1950) — precertification required for Medicare Advantage members only Lupron depot (leuprolide acetate, J9217) Lutrate (leuprolide acetate, J1954) Trelstar (triptorelin pamoate, J3315) Zoladex (goserelin, J9202)
Lyfgenia (lovotibeglogene autotemcel, J3394) — precertification required for the drug and site of care Contact National Medical Excellence at 1-877-212-8811 (TTY: 711) Lymphir (denileukin diftitox-cxdl, J9161) Lynozyfic IV (Linvoseltamab – gcpt, J9601) Monjuvi (tafasitamab-cxix, J9349) Multiple sclerosis drugs (precertification required for the drug and site of care): Briumvi (ublituximab, J2329) Lemtrada (alemtuzumab, J0202)
Ocrevus (ocrelizumab, J2350) Ocrevus Zunovo (ocrelizumab and hyaluronidase- ocsq, J2351) Other drugs and medical injectables (continued) *For precertification when the member is enrolled in a Commercial plan, call 1-855-240-0535 (TTY: 711). Or fax applicable request forms to 1-877-269-9916 (TTY: 711).

27 General info Services Special programs How to submit Drugs Tyruko (natalizumab-sztn, Q5134) Tysabri (natalizumab, J2323) Muscular dystrophy drugs: (precertification required for the drug and site of care): Amondys 45 (casimersen, J1426)
Elevidys (delandistrogene moxeparvovec, J3490, J3590, C9399) Exondys 51 (eteplirsen, J1428) Viltepso (viltolarsen, J1427) Vyondys 53 (golodirsen, J1429) Mvasi (bevacizumab-awwb, Q5107) — precertification required for the drug and site of care for oncology indications only Myalept (metreleptin, J3490, J3590) — precertification required for Commercial members only Niktimvo (axatilimab-csfr, J9038) Nulibry (fosdenopterin, J1809) Omisirge (omidubicel, J3490, J3590, C9399, J9999) — precertification required for the drug and site of care Contact National Medical Excellence at 1-877-212-8811 (TTY: 711) Ophthalmic injectables: Ahzantive (aflibercept-mrbb, Q5150) Beovu (brolucizumab-dbll, J0179) Byooviz (ranibizumab-nuna, Q5124) Cimerli (ranibizumab-eqrn, Q5128) Encelto (revakinagene taroretcel-lwey, J3403) Ophthalmic injectables (continued): Enzeevu (aflibercept-abzv, Q5149) Eydenzelt (aflibercept-boav J3490, J3590, C9399)—precertification required effective April 1, 2026 Eylea (aflibercept, J0178) Eylea HD (aflibercept, J0177) Izervay (avacincaptad pegol, J2782) Lucentis (ranibizumab, J2778) Luxturna (voretigene neparvovec-rzyl, J3398) — precertification required for the drug and site of care Nufymco (ranibizumab-leyk J3490, J3590, C9399)— precertification required Effective May 1, 2026 Opuviz (aflibercept-yszy, Q5153) Pavblu (aflibercept-ayyh, Q5147) Susvimo (ranibizumab, J2779)
Syfovre (pegcetacoplan, J2781) Tepezza (teprotumumab-trbw, J3241) — precertification required for the drug and site of care Vabysmo (faricimab-svoa, J2777) Yesafili (aflibercept-jbvf, Q5155) Osteoporosis drugs: Aukelso (denosumab-kyqq, Q5161)— precertification required effective April 1, 2026 Bildyos (denosumab-nxxp, Q5162) — precertification required effective April 1, 2026 Bilprevda (denosumab-nxxp, Q5162)— precertification required Effective April 1, 2026 Bomyntra (denosumab-bnht, Q5158) Other drugs and medical injectables (continued) For precertification when the member is enrolled in a Commercial plan, call 1-855-240-0535 (TTY: 711). Or fax applicable request forms to 1-877-269-9916 (TTY: 711).

28 Services Special programs General info How to submit Drugs Bosaya (denosumab-kyqq, Q5161) — precertification required Effective April 1, 2026 Conexxence (denosumab-bnht, Q5158) denosumab-bnht (J3490, J3590, C9399) denosumab-dssb (J3490, J3590, C9399) Enoby (denosumab-qbde, J3490, J3590, C9399)— precertification required Effective April 1, 2026 Evenity (romosozumab-aqqg, J3111) Forteo (teriparatide, J3110) — precertification required for Medicare Advantage members only Jubbonti (denosumab-bbdz, Q5136) Jubereq (denosumab-desu, J3490, J3590, C9399) — precertification required effective April 1, 2026 Miacalcin (calcitonin, J0630) — precertification required for Medicare Advantage members only Osenvelt (denosumab-bmwo, Q5157) Ospomyv (denosumab-dssb, Q5159) Osvyrti (denosumab-desu, J3490, J3590, C9399) — precertification required effective April 1, 2026 Ponlimsi (denosumab-adetJ3490, J3590, C9399) — precertification required effective May 1, 2026 Prolia (denosumab, J0897) Stoboclo (denosumab-bmwo, Q5157) Teriparatide (J3110) — precertification required for Medicare Advantage members only Wyost (denosumab-bbdz, Q5136) Xbryk (denosumab-dssb, J3490, J3590, C9399) Xtrenbo (denosumab-qbde J3490, J3590, C9399)— precertification required Effective April 1, 2026 Oxlumo (lumasiran, J0224) — precertification required for the drug and site of care Paclitaxel protein-bound particles (American Regent, J9264) — precertification required for Medicare Advantage members only Padcev (enfortumab vedotin, J9177) Paroxysmal nocturnal hemoglobinuria (PNH) drugs (precertification required for the drug and site of care): Bkemv (eculizumab-aaeb, Q5152) Epysqli (eculizumab-aagh, Q5151) Soliris (eculizumab, J1299) Ultomiris (Ravulizumab-cwvz, J1303) Parsabiv (etelcalcetide, J0606) — precertification required for Commercial members only PD1/PDL1 drugs (precertification required for the drug and site of care): Bavencio (avelumab, J9023) Imfinzi (durvalumab, J9173) Jemperli (dostarlimab-gxly, J9272) Keytruda (pembrolizumab, J9271) Keytruda Qlex (pembrolizumab and berahyaluronidase alfa-pmph, J9277) Libtayo (cemiplimab-rwlc, J9119) Loqtorzi (toripalimab-tpzi, J3263) Opdivo (nivolumab, J9299) Opdivo Qvantig (nivolumab and hyaluronidase- nvhy, J9289)
Opdualag (nivolumab and relatlimab-rmbw, J9298) Other drugs and medical injectables (continued) *For precertification when the member is enrolled in a Commercial plan, call 1-855-240-0535 (TTY: 711). Or fax applicable request forms to 1-877-269-9916 (TTY: 711).

29 General info Services Special programs How to submit Drugs penpulimab-kcqx (J3490,J3590, C9399) Tecentriq (atezolizumab, J9022) Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs, J9024) Tevimbra (tislelizumab, J9329) Unloxcyt (cosibelimab-ipdl, J9275) Zynyz (retifanlimab-dlwr, J9345) Pedmark (sodium thiosulfate, J0208) Pemfexy (pemetrexed, J9304) — precertification required for Medicare Advantage members only Pemrydi RTU (pemetrexed, J9324) — precertification required for Medicare Advantage members only Polivy (polatuzumab vedotin-piiq, J9309) Provenge (sipuleucel-T, Q2043) Pulmonary arterial hypertension drugs: All epoprostenol sodium, sildenafil citrate and treprostinil sodium products Flolan (epoprostenol sodium, J1325) Remodulin (treprostinil sodium, J3285, J7686) Tyvaso (treprostinil, J3285, J7686) Veletri (epoprostenol sodium, J1325) Ventavis (iloprost, Q4074) Winrevair (sotatercept-csrk, J3490, J3590, C9399) Radiopharmaceutical drugs: Metastron (Strontium-89 Chloride injection, A9600) Pluvicto (lutetium Lu 177 vipivotide tetraxetan, A9607) Reblozyl (luspatercept-aamt, J0896) Redemplo (plozasiran, J3490) — precertification required for drug and site of care effective April 1, 2026 Respiratory injectables (precertification required for the drug and site of care): Cinqair (reslizumab, J2786) Exdensur (depemokimab, C9399, J3590)— precertification required effective April 1, 2026 Fasenra (benralizumab, J0517) Nucala (mepolizumab, J2182) Omlyclo (omalizumab-igec, Q5154) Tezspire (tezepelumab-ekko, J2356) Xolair (omalizumab, J2357) Rivfloza (nedosiran, J3490, J3590, C9399) — precertification required for the drug and site of care Rybrevant (amivantamab-vmjw, J9061) Rybrevant Faspro (amivantamab and hyaluronidase-lpuj, C9399, J9999)— precertification required for the drug and site of care effective April 1, 2026 Ryoncil (remestemcel-L, J3402) Ryplazim (plasminogen, human-tvmh, J2998) Rytelo (imetelstat, J0870) Saphnelo (anifrolumab-fnia, J0491) — precertification required for the drug and site of care Sarclisa (isatuximab-irfc, J9227) Other drugs and medical injectables (continued) *For precertification when the member is enrolled in a Commercial plan, call 1-855-240-0535 (TTY: 711). Or fax applicable request forms to 1-877-269-9916 (TTY: 711).

30 General info Services Special programs How to submit Drugs Skysona/Lenti-D (elivaldogene autotemcel or eli- cel, J3387) — precertification required for the drug and site of care. Contact National Medical Excellence at 1-877-212-8811 (TTY: 711) Somatostatin agents: Lanreotide (cipla, J1932) — precertification required for the drug and site of care Sandostatin (octreotide, J2354) Sandostatin LAR (octreotide acetate, J2353) — precertification required for the drug and site of care Signifor (pasireotide, J3490, J3590) — precertification required for Commercial members only
Signifor LAR (pasireotide, J2502) Somatuline (lanreotide, J1930) — precertification required for the drug and site of care Somavert (pegvisomant, J3490, J3590) — precertification required for Commercial members only Spinraza (nusinersen, J2326) — precertification required for the drug and site of care Spravato (esketamine, J0013) Synagis (palivizumab, 90378) Talvey (talquetamab-tgvs, J3055) Tecelra (afamitresgene autoleucel, Q2057) — precertification required for the drug and site of care Contact National Medical Excellence at 1-877-212-8811 (TTY: 711) Tecvayli (teclistamab-cqyv, J9380) Tivdak (tisotumab vedotin-tftv, J9273) Treanda (bendamustine HCl, J9033) Trodelvy (sacituzumab govitecan-hziy, J9317) Tzield (teplizumab-mzwv, J9381) Uplizna (inebilizumab-cdon, J1823) — precertification required for the drug and site of care Vectibix (panitumumab, J9303) Vegzelma (bevacizumab-adcd, Q5129) — precertificatoin required for the drug and site of care for oncology indications Velcade (bortezomib, J9041) Commercial plans — precertification required for multiple myeloma only Medicare plans — precertification required for all diagnoses Viscosupplements: Durolane (Hyaluronic acid, J7318) — precertification required for Commercial members only Euflexxa (1% sodium hyaluronate, J7323) — precertification required for Commercial members only Gel-One (cross-linked hyaluronate, J7326) Gelsyn-3 (sodium hyaluronate 0.84%, J7328) Genvisc 850 (sodium hyaluronate, J7320) Hyalgan (sodium hyaluronate, J7321) Other drugs and medical injectables (continued) *For precertification when the member is enrolled in a Commercial plan, call 1-855-240-0535 (TTY: 711). Or fax applicable request forms to 1-877-269-9916 (TTY: 711).

31 General info Services Special programs How to submit Drugs Hymovis (high molecular weight viscoelastic hyaluronan, J7322) Hymovis One (viscoelastic hyaluronan, J7322)— precertification required effective April 1, 2026 Monovisc (high molecular weight hyaluronan,
J7327) Orthovisc (high molecular weight hyaluronan, J7324) Supartz FX (sodium hyaluronate, J7321) Synojoynt (1% sodium hyaluronate, J7331) Synvisc, Synvisc-One (hylan G-F 20, J7325) — precertification required for Commercial members only Triluron (sodium hyaluronate, J7332) TriVisc (sodium hyaluronate, J7329) Visco 3 (sodium hyaluronate, J7321) Vivimusta (bendamustine hydrochloride, J9056) Vyjuvek (beremagene geperpavec, J3490, J3590, C9399) Vyloy (zolbetuximab-clzb, J1326) Waskyra (etuvetidigene autotemcel, J3490, J3590, C9399)— precertification required for the drug and site of care effective April 1, 2026 Xgeva (denosumab, J0897) Yartemlea (narsoplimab J3490, J3590, C9399) — precertification required effective April 1, 2026 Yervoy (ipilimumab, J9228) — precertification required for the drug and site of care Yondelis (trabectedin, J9352) Zepzelca (lurbinectedin, J9223) Zevaskyn (prademagene zamikeracel, J3389) — precertification required for the drug and site of care Zilretta (triamcinolone acetonide extended release injectable suspension, J3304) — precertification required for Medicare Advantage members only Zirabev (bevacizumab-bvzr, Q5118) — precertification required for the drug and site of care for oncology indications only Zolgensma (onasemnogene abeparvovec-xioi, J3399) — precertification required for the drug and site of care Zulresso (brexanolone, J1632) Zusduri (mitomycin J9282) Zynlonta (loncastuximab tesirine-lpyl, J9359) Zynteglo (betibeglogene autotemcel, J3393) — precertification required for the drug and site of care Contact National Medical Excellence at 1-877-212-8811 (TTY: 711). Other drugs and medical injectables (continued) For precertification when the member is enrolled in a Commercial plan, call 1-855-240-0535 (TTY: 711). Or fax applicable request forms to 1-877-269-9916 (TTY: 711).

Special programs 32 General info Services Drugs How to submit Special programs Breast and ovarian cancer susceptibility screening (BRCA) 81163, 81165, 81212, 81215, 81216, 81217, 81432 81162 (precertification required for Medicare Advantage members only) Through our expanded national provider network: • Quest Diagnostics, Inc — 1-866-436-3463 (TTY: 711) • Ambry Genetics — 1-866-262-7943 (TTY: 711) • Baylor Miraca Genetics Laboratories, LLC — 1-800-411-4363 (TTY: 711) • Genpath and BioReference — 1-800-633-4522 (TTY: 711) • LabCorp — 1-888-522-2677 (TTY: 711) • Medical Diagnostic Lab, LLC — 1-877-269-0090 (TTY: 711) • Myriad Genetics Laboratories, Inc. — 1-800-469-7423 (TTY: 711) • Natera —877-446-6860 (TTY: 711) You can use the online BRCA form under the “Medical precertification” section to send precertification requests. Find genetic counselors online For a list of our contracted providers, including our telephonic provider (Informed DNA), go to our provider directory. Cataract surgery Florida Medicare Contact iCare Health Solutions to ask for preauthorization for cataract surgery-related requests. You can reach iCare at 1-855-373-7627 (TTY: 711).

33 General info Services Drugs How to submit Special programs Chiropractic precertification Chiropractic precertification is required only in the states listed below. • Arizona (AZ) - HMO-based plan members only Through American Specialty Health (ASH) 1-800-972-4226 (TTY: 711) • California (CA) -HMO-based plan and group Medicare members only Through American Specialty Health (ASH) 1-800-972-4226 (TTY: 711) • Georgia ( GA)- All members (with commercial and Aetna Medicare Advantage plans included Through American Specialty Health (ASH) 1-800-972-4226 (TTY: 711) Diagnostic cardiology (cardiac rhythm implantable devices, cardiac catheterization) 33206, 33207, 33208, 33212, 33213, 33214, 33221, 33224, 33225, 33227, 33228, 33229, 33230, 33231, 33240, 33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273, 33274, 33275, 33289, 33882, 0515T, 0516T, 0517T, 0519T, 0520T, 0614T 75580, 78429, 78430, 78431, 78432, 78433, 78434, 78451, 78452, 78453, 78454, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78496, 93350, 93351, 93451, 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93593, 93594, 93595, 93596, 93597, C9762, C9763, 0742T Precertification is not required for Student Health and Allina Health | Aetna plans. Precertification is required for cardiac rhythm implants for the Foreign Service Benefit Plan, MHBP and Rural Carrier Benefit Plan. It isn’t required for cardiac catheterization. To authorize services, please use the contact information on the back of the member’s ID card. These plans don’t use EviCore. Precertification is required for all members with plans applicable to this precertification list unless services are emergent: • Providers in all states where applicable, should contact EviCore healthcare to request preauthorization. You can reach EviCore healthcare:

• Online at Evicore.com
• By phone at 1-888-622-7329 (TTY: 711) between 7 AM and 8 PM ET
• By fax at 1-800-540-2406 (TTY: 711), Monday through Friday during normal business hours, or as required by federal or state regulations Special programs (continued)

34 General info Services Drugs How to submit Special programs Hip and knee arthroplasties 27091, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27446, 27447, 27486, 27487, 27488, S2118 • Go to Availity.com to start a request. • Commercial plans: 1-888-632-3862 (TTY: 711) • Medicare plans: 1-800-624-0756 (TTY: 711) Precertification is not required for Student Health and Allina Health | Aetna plans. For the Foreign Service Benefit Plan, MHBP and Rural Carrier Benefit Plan, please use the contact information on the back of the member’s ID card. Precertification is required for all members with plans applicable to this list unless services are emergent. Home health care G0151, G0152, G0153, G0155, G0156, G0157, G0158, G0159, G0160, G0161, G0162, G0299, G0300, G0493, G0494, G0495, G0496 Precertification through Carelon Post Acute Solutions (formerly myNEXUS) is required for all Medicare home health–related requests in Florida, Georgia, Kentucky, Ohio, Oklahoma, Texas and Virginia. This includes in-home skilled nursing, physical therapy, occupational therapy, speech therapy, home health aide services and medical social work. Exception: Oklahoma and Virginia Dual Special Needs Plans. Providers in these states should contact Carelon for precertification • Carelon Post Acute Solutions dedicated (Aetna®) provider line: 1-833-585-6262 (TTY: 711) • Claims submission or claim status: 1-833-241-0428 (TTY: 711) • Submit request through Carelon Post Acute Solutions provider portal:

• Portal.mynexuscare.com (this link will redirect you to the Carelon portal website)
• Carelon portal link (this link goes directely to the Carelon portal without redirection) • Carelon Post Acute Solutions provider directory: Carelon Post Acute Solutions care.com/ providerdirectory • Fax Home Health Care Authorization Request Form to: 1-866-996-0077 (TTY: 711) Special programs (continued)

35 General info Services Drugs How to submit Special programs Precertification is not required for Student Health and Allina Health | Aetna plans. Precertification is required for all members with plans applicable to this precertification list unless services are emergent. • The Foreign Service Benefit Plan, MHBP and Rural Carrier Benefit Plan don’t use EviCore for precertification. To authorize services, please use the contact information on the back of the member’s ID card. Precertification is required for all Medicare Advantage members in New Jersey, New York, Pennsylvania and West Virginia. This applies to home health–related services, including in-home skilled nursing, physical therapy, occupational therapy, speech therapy, home health aide services and medical social work. Providers in these states should contact EviCore healthcare for precertification. • EviCore healthcare provider line: 1-888-622-7329 (TTY: 711) • Submit request through EviCore healthcare provider portal: EviCore • Fax Home Health Care Authorization Request form to: 1-866-705-3574 (TTY: 711) Infertility program — 1-800-575-5999 (TTY: 711) 58970, 58974, 58976, 76948, 89250, 89251, 89253, 89254, 89255, 89257, 89258, 89264, 89268, 89272, 89280, 89281, 89337, 89342, 89346, 89352, S4011, S4013, S4014,S4015, S4016, S4017, S4018, S4020, S4021, S4022, S4023, S4025, S4035 Medical and radiation oncology
Florida Medicare Oncology-related infused and injectable chemotherapeutic agents, supportive/symptom management medications and radiation treatments services administered in a physician’s office, outpatient hospital or ambulatory setting, will be submitted to Evolent for prior authorization for members 18 years of age and older with a diagnosis within the following ranges: Cancer diagnosis: C00-D09.0; D37.01-D49.9; D59.5; D61.810; D61.82; D63.0; D64.0-64.81; D70.1; D72.822; D75.81; E34.0; D3A.8; D3A.00; D3A.010-D3A.098 Medical and radiation oncology services related: • Regimen review of cancer treatments; including supportive drugs (including new-to-market medications and new indications) paid under the medical benefit, including review of combination regimens containing both medical and pharmacy benefit drug, that fall within Delegated Entity’s range of in-scope GPI04 range. Radiation oncology services related: • Brachytherapy, Conformal, IMRT, IGRT, Stereotactic Radiation, Radiopharmaceuticals, Proton & Neutron Beam Therapy Special programs (continued)

36 General info Services Drugs How to submit Special programs Special programs (continued) Treating provider’s office must submit prior authorization requests to Evolent. Precertification is required for all Medicare members residing in Florida (FL). Evolent provider portal at Evolent.com/provider-portal For medical oncology & radiation oncology services: • Medical oncology: 1.888.999.7713 (option 2) • Radiation oncology: 1.888.999.7713 (option 3) Hours of operation : Monday through Friday, 8AM to 8PM ET Evolent provider portal self-registration available at: My.newcenturyhealth.com/
For questions regarding Evolent’s program scope or portal training needs, please contact Evolent Provider Solutions at providertraining@evolent.com Precertification isn’t required for Student Health and Allina Health | Aetna plans. The Foreign Service Benefit Plan, MHBP and Rural Carrier Benefit Plan don’t use EviCore for precertification. To authorize services, please use the contact information on the back of the member’s ID card. National Medical Excellence Program® By phone at 1-877-212-8811 (TTY: 711) for the following: • Chimeric Antigen Receptor T-Cell Therapy (CAR-T) drugs All major organ transplants (and evaluations), including but not limited to: • Kidney • Liver • Heart • Lung • Pancreas • Bone marrow replacement • Stem cell transfer after high-dose chemotherapy

37 General info Services Drugs How to submit Special programs Special programs (continued) Pain management 27096, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0627T, 0628T, 0629T, 0630T G0259, G0260 Precertification isn’t required for Student Health and Allina Health | Aetna plans. Precertification is required for all members with plans applicable to this precertification list unless services are emergent. • The Foreign Service Benefit Plan, MHBP and Rural Carrier Benefit Plan don’t use EviCore for precertification. To authorize services, please use the contact information on the back of the member’s ID card. • To request preauthorization, providers in all states where applicable should contact EviCore healthcare:

• Online at Evicore.com
• By phone at 1-888-622-7329 (TTY: 711) between 7 AM and 8 PM ET By fax at 1-855-774-1319 (TTY: 711), Monday through Friday, during normal business hours, or as required by federal or state regulations Peripheral arterial disease (PVD) 37254, 37255, 37256, 37257, 37258, 37259, 37260, 37261, 37262, 37263, 37264, 37265, 37266, 37267, 37268, 37269, 37270, 37271, 37272, 37273, 37274, 37275, 37276, 37277, 37278, 37279, 37280, 37281, 37282, 37283, 37284, 37285, 37286, 37287, 37288, 37289, 37290, 37291, 37292, 37293, 37294, 37295 Precertification isn’t required for Student Health and Allina Health | Aetna plans. Precertification is required for all members with plans applicable to this list unless services are emergent. • Precertification isn’t required for the Foreign Service Benefit Plan, MHBP and Rural Carrier Benefit Plan • To request preauthorization, providers in all states where applicable should contact EviCore healthcare:
• Online at Evicore.com
• By phone at 1-888-622-7329 (TTY: 711) between 7 AM and 8 PM ET By fax at 1-800-540-2406 (TTY: 711), Monday through Friday, during normal business hours, or as required by federal or state regulations

38 General info Services Drugs How to submit Special programs Special programs (continued) Polysomnography (attended sleep studies) 95782, 95783, 95805, 95807, 95808, 95810, 95811 Precertification isn’t required for Student Health and Allina Health | Aetna plans. The Foreign Service Benefit Plan, MHBP and Rural Carrier Benefit Plan don’t use EviCore for precertification. To authorize services, please use the contact information on the back of the member’s ID card. Precertification is required for all members with plans applicable to this list when performed in any facility except inpatient, emergency room and observation bed status. • Providers in all states where applicable should contact EviCore healthcare to request preauthorization. You can reach EviCore healthcare:

• Online at Evicore.com
• By phone at 1-888-622-7329 (TTY: 711) between 7 AM and 8 PM ET By fax at 1-800-540-2406 (TTY: 711), Monday through Friday during normal business hours, or as required by federal or state regulations Pre-implantation genetic testing — 1-800-575-5999 (TTY: 711) 89290, 89291

39 General info Services Drugs How to submit Special programs Special programs (continued) Radiology imaging 70336, 70450, 70460, 70470, 70471, 70472, 70473, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71250, 71260, 71270, 71271, 71275, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72191, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 73200, 73201, 73202, 73206, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73700, 73701, 73702, 73706, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 74261, 74262, 74263, 74712, 74713, 75557, 75559, 75561, 75563, 75565, 75571, 75572, 75573, 75574, 75635, 76380, 76390, 77021, 77022, 77046, 77047, 77048, 77049, 77084, 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, 0609T, 0610T, 0611T, 0612T, 0633T, 0634T, 0635T, 0636T, 0637T, 0638T, 0710T, 0711T, 0712T, 0713T, C8900, C8901, C8902, C8903, C8905, C8906, C8908, C8909, C8910, C8911, C8912, C8913, C8914, C8918, C8919, C8920, C8931, C8932, C8933, C8934, C8935, C8936, S8035, S8037, S8042, S8092 Precertification isn’t required for Student Health and Allina Health | Aetna plans. The Foreign Service Benefit Plan, MHBP and Rural Carrier Benefit Plan don’t use EviCore for precertification. To authorize services, please use the contact information on the back of the member’s ID card. All members with plans that use this list need precertification. Exception: When members receive care in any inpatient facility or emergency room, or in an observation bed status. In addition to precertification, some members will have site-of-care requirements for MRI and CT scans when services are requested in a hospital outpatient setting.
• Providers in all states where applicable should contact EviCore healthcare to request preauthorization. • You can reach EviCore healthcare:

• Online at Evicore.com
• By phone at 1-888-622-7329 (TTY: 711) between 7 AM and 8 PM ET
• By fax at 1-800-540-2406 (TTY: 711), Monday through Friday during normal business hours or as required by federal or state regulations

40 Special programs (continued) How to General Special Services Drugs submit info programs Radiation oncology 77371, 77372, 77373, 77387, 77402, 77407, 77412, 77423, 77424, 77425, 77437, 77438, 77439, 77600, 77605, 77610, 77615, 77620, 77761, 77762, 77763, 77767, 77768, 77770, 77771, 77772, 77778,79005, 79101, A9590, G0339, G0340, 0395T, 0747T Proton beam radiotherapy: 77520, 77522, 77523, 77525 • Complex • 3D conformal • Stereotactic radiosurgery (SRS) • Stereotactic body radiation therapy (SBRT) • Image guided radiation therapy (IGRT) • Intensity-modulated radiation therapy (IMRT) • Proton beam therapy • Neutron beam therapy • Brachytherapy • Hyperthermia • Radiopharmaceuticals Precertification isn’t required for Student Health and Allina Health | Aetna plans. The Foreign Service Benefit Plan, MHBP and Rural Carrier Benefit Plan don’t use EviCore for precertification. To authorize services, please use the contact information on the back of the member’s ID card. Precertification is required for all members with HMO-based plans, Aetna Medicare Advantage plans and fully insured Aetna® Commercial plans. This applies to services performed in any facility except inpatient settings, emergency rooms or observation bed status. For fully insured Commercial and Medicare plans (excluding Florida Medicare plan members), you must contact EviCore Healthcare to request preauthorization. • Online at Evicore.com • By phone at 1-888-622-7329 (TTY: 711) • By fax at 1-800-540-2406 (TTY: 711), Monday through Friday during normal business hours or as required by federal or state regulations

41 Special programs (continued) How to General Special Services Drugs submit info programs Site of service Also see Special programs: Radiology imaging Precertification is required when all of the following apply: • The member is enrolled in an Aetna® fully insured Commercial plan or a self-insured plan that has opted in to the program; and • Service(s) is in an outpatient hospital setting (NOT an ambulatory surgical facility or office setting); and • The procedure is one of the following:

• Breast tissue excision (19120)
• Complex wound repair (13101, 13132)
• Cystourethroscopy (52000)
• Septoplasty (30520)
• Skin tissue transfer or rearrangement (14040, 14060, 14301)
• Tenodesis of long tendon of biceps (23430)
• Turbinate resection (30140) Whole exome sequencing (WES) and whole genome sequencing (WGS) 81415, 81416, 81417, 81425, 81426, 81427 0094U, 0214U, 0215U, 0335U, 0336U, 0425U, 0426U Through our expanded national provider network: • Ambry Genetics — 1-866-262-7943 (TTY: 711) • BaylorGenetics — 1-800-411-4363 (TTY: 711) • GeneDx — 1-888-729-1206 (TTY: 711) • Invitae — 1-800-436-3037 (TTY: 711) • LabCorp — 1-866-248-1265 (TTY: 711) • Quest Diagnostics, Inc — 1-866-436-3463 (TTY: 711)

See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area. Participating physicians, hospitals and other health care providers are independent contractors and are neither agents nor employees of Aetna®. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change. Out-of-network/non-contracted providers are under no obligation to treat Aetna members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. The formulary, provider and/or pharmacy network may change at any time. You will receive notice when necessary. ©2026 Aetna Inc. 1013000-01-39 (05/26)