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The following additions to Aetna’s National Precertification List (NPL) will take effect on January 1, 2013, unless otherwise noted.

• The treating surgeon is required to obtain precertification for cervical, thoracic, or lumbar laminectomy and laminotomy procedures:
  • For inpatient procedures effective September 1, 2012
  • For outpatient procedures effective December 1, 2012
• Elelyso™ (taliglucerase alfa) – effective August 21, 2012

• Infusible/Injectable Immunologic Agents (Aetna members requiring treatment with an infusible agent in this class should be prescribed Remicade® as the formulary preferred infusible.  Members requiring treatment with an injectable agent in this class should be prescribed Enbrel®, Humira®, Simponi® or Stelara® as formulary preferred injectable)

  • Actemra® (tocilizumab)
  • Amevive® (alefacept)
  • Cimzia® (certolizumab pegol)
  • Enbrel (etanercept)
  • Humira (adalimumab)
  • Kineret® (anakinra)
  • Orencia® (abatacept)
  • Remicade (infliximab)
  • Rituxan® (rituximab)
    • Currently requires precertification for rheumatoid arthritis
    • Precertification required for all conditions effective January 1, 2013
  • Simponi (golimumab)
  • Stelara (ustekinumab)
• Omontys® (peginesatide) – effective August 21, 2012
  • Precertification for a period of 16 weeks

• Wet age-related macular degeneration treatments

  • *Eylea® (aflibercept)
  • *Macugen® (pegaptanib sodium injection)
  • *Lucentis® (ranibizumab injection)

The following modifications to Aetna’s NPL will take effect on January 1, 2013, unless otherwise indicated. Please note that precertification approvals are valid for 6 months for the date of issue, unless stated otherwise at the time of precertification. Approvals for drugs marked with a single asterisk (*) are valid for 12 months from the date of issue.

• Injectable infertility drugs
  • Precertification and vial management for injectable infertility medications currently applies to female members enrolled in commercial plans
    • Effective January 1, 2013, the precertification requirement will also apply to male members enrolled in commercial plans

• Osteoporosis drugs – injectable and Xgeva®

  • Aetna will update Clinical Policy Bulletin #0804 (Denosumab [Prolia and Xgeval]) on January 1, 2013 to show a preferred product for the following medications currently on the precertification list for osteoporosis indications:
    • *Aredia® (pamidronate)
    • *Xgeva (denosumab)
      • Expanding precertification requirement for Xgeva (denosumab)
      • Aetna member requiring Xgeva (denosumab) must have a documented trial and failure, contraindication or intolerance of either Aredia (pamidronate) or Zometa® (zolendronic acid)
      • Requirement does not apply to Aetna members receiving treatment on Xgeva (denosumab) prior to the expanded requirements effective January 1, 2013
    • *Zometa (zoledronic acid)

• Outpatient surgical scopes

  • Effective September 1, 2012:
    • Notification is no longer required for bronchoscopy, cystoscopy, hysteroscopy, knee arthroscopy, laparoscopic cholecystectomy and shoulder arthroscopy
    • Notification for colonoscopy and upper GI endoscopy remains a requirement

Negative Pressure Wound Therapy will be deleted from Aetna’s NPL effective January 1, 2013.  The removal of a service from the precertification list does not mean that the services will be covered.  The services are still subject to review upon submission of the claim for services, and may be denied in accordance with the terms of the member’s plan.

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