Effective for dates of service on or after January 1, 2012, we will implement important changes to the list of services and drugs that require precertification for Medicare Advantage HMO members.

The following precertification requirements will be added for Medicare Advantage products in all settings:

The following precertification requirements will be removed for Medicare Advantage products in all settings:

As we proceed through this transition, it is very important for providers to continue to refer to the most current precertification requirements lists or to use the NaviNet? web portal to verify member-specific requirements. Failure to obtain precertification for any of the services or drugs that require it may result in a reduction in payment or nonpayment for the services not precertified.

Please call 1-800-275-2583 if you have any questions about these upcoming changes.

Note: These changes were originally announced in the June edition of Partners in Health Update and went into effect for Pennsylvania and Delaware commercial products for dates of service on or after September 1, 2011.

Changes will also be made for New Jersey commercial members, but the effective date has yet to be determined. More information will be available in future editions of Partners in Health Update.

Potentially cosmetic procedures that will require precertification Blepharoplasty/ptsosis repair Hair transplant Rhinoplasty Breast: reconstruction, reduction, augmentation, mammoplasty, mastopexy, insertion, and removal of breast implants Injectable dermal fillers Rhytidectomy Canthopexy/canthoplasty Keloid removal Scar revision Cervicoplasty Labiaplasty Skin closures including: skin grafts,skin flaps, and tissue grafts Chemical peels Lipectomy, liposuction, or any other excess fat removal procedure Sex reassignment surgery Dermabrasion Orthognathic surgery procedures including, but not limited to: bone graft, genioplasty, osteoplasty, mentoplasty, osteotomies Surgical treatment of gynecomastia Excision of excessive skin and/or subcutaneous tissue Otoplasty Surgery for varicose veins, including perforators and sclerotherapy Genetically and bio-engineered skin substitutes for wound care
Additional infusion drugs that will require precertification Abraxane? Enzyme replacement (Lumizyme?, Replagal?*, Uplyso?*, VPRIV?) Istodax? Alimta? Flolan? Jevtana? Alpha 1 inhibitors (Aralast NPTM, GlassiaTM, Prolastin? C, Zemaira?) Folotyn? Provenge? ArzerraTM Gammaplex? (IVIG) Psoriasis/rheumatoid arthritis (Actemra?) Belatacept HalavenTM Remodulin? Benlysta? Hemophilia factors Soliris? C1 esterase inhibitors (Berinert?,Cinryze?) Herceptin? DM1* YervoyTM CorifactTM (factor drug)
Additional injectable drugs that will require precertification Kalbitor? MakenaTM Stelara? Lucentis? OmaproTM* XgevaTM Macugen? Prolia? Xolair?

*This drug is pending approval from the U.S. Food and Drug Administration.