1-866-503-0857 For other lines of business: Please use other form. Note: Avsola is preferred for MA plans. Preferred status for MAPD plans varies based on indication. See section G. G. CLINICAL INFORMATION (continued) - Required clinical information must be completed in its entirety for all precertification requests. Continued on next pagePhone: 1-866-752-7021 Medication Precertification Request FAX: 1-888-267-3277 For Medicare Advantage Part B: Page 2 of 2 Phone: 1-866-503-0857 (All fields must be completed and legible for precertification review) FAX: 1-844-268-7263 Patient First Name . Patient Last Name . Patient Phone . Patient DOB . H. ACKNOWLEDGEMENT Request Completed By1-866-752-7021 FAX: 1-888-267-3277 For Medicare Advantage Part B: Phone: 1-866-503-0857 FAX: 1-844-268-7263 Patient First Name . Patient Last Name . Patient Phone . Patient DOB . G. CLINICAL INFORMATION - Required clinical information must be completed in its entirety for all precertification requests.1-866-752-7021 Medication Precertification Request FAX: 1-888-267-3277 Page 2 of 2 For Medicare Advantage Part B: (All fields must be completed and legible for precertification review.) Phone: 1-866-503-0857 FAX: 1-844-268-7263 G. CLINICAL INFORMATION (continued)For Medicare Part B plans, call (866) 503-0857, or fax (844) 268-7263. Hepatitis B Immune Globulin. Criteria for Initial Approval. Aetna considers hepatitis B immune globulin medically necessary for members who have had contact with an individual diagnosed with hepatitis B virus (HBV). Risk groups include infants born to hepatitis B surface ...Note: Precertification review for Rituxan is handled through Aetna Specialty Precert Unit at 1-866-503-0857. Policy: Note: The provision of physician samples does not guarantee coverage under the provisions of the pharmacy benefit. All criteria below must be met in order to obtain coverage of rituximab (Rituxan).503 Sunport Lane, Orlando, FL 32809 . Phone: 1-866-503-0857 . FAX: 1-888-267-3277 . For Medicare Advantage Part B: FAX: 1-844-268-7263 (All fields must be completed and legible for Precertification Review) Please indicate: Start of treatment: Start date / / Continuation of therapy: Date of last treatment / / Precertification Requested By:1-866-752-7021 Injectable Precertification Request FAX: 1-888-267-3277 Page 2 of 4 For Medicare Advantage Part B: (All fields must be completed and legible for precertification review.) Phone: 1-866-503-0857 FAX: 1-844-268-7263 – Patient First Name . Patient Last Name . Patient Phone . Patient DOB . G. CLINICAL INFORMATION (continued)Aetna Precertification Notification 503 Sunport Lane, Orlando, FL 32809 Phone: 1-866-503-0857 FAX: 1-888-267-3277 For Medicare Advantage Part B: FAX: 1-844-268-7263 Patient First Name Patient Last Name Patient Phone Patient DOB G. CLINICAL INFORMATION (continued) - Required clinical information must be completed in its entirety for all ...503 Sunport Lane, Orlando, FL 32809. Phone: 1-866-503-0857. FAX: 1-888-267-3277. For Medicare Advantage Part B: FAX: 1-844-268-7263 (All fields must be completed and legible for Precertification Review.) Please indicate: Start of treatment: Start date. Continuation of therapy: Date of last treatment. Precertification Requested By: Phone: Fax: A ...Medication Precertification Request . FAX: 1-888-267-3277. Page 1 of 2 For Medicare Advantage Part B: (All fields must be completed and legible for precertification review.) Phone: 1-866-503-0857 FAX: 1-844-268-7263. Please indicate: Start of treatment: Start date / / Continuation of therapy: Date of last treatment / /Policy: Precertification Criteria; Under some plans, including plans that use an open or closed formulary, Olysio is subject to precertification.If precertification requirements apply Aetna considers these medications to be medically necessary for those members who meet all of the following precertification criteria.1-844-268-7263. PHONE: 1-866-503-0857 (TTY: 711) For other lines of business: Please use other form. Note: Vabysmo is non-preferred. The preferred products are bevacizumab (Avastin) first followed by Byooviz or Eylea/Eylea HD. Avastin (C9257) and bevacizumab biosimilars do not require precertification for ophthalmic use.PHONE: 1-866-503-0857 (TTY: 711) For other lines of business: Please use other form. Note: Beovu is non-preferred. The preferred products are bevacizumab (Avastin) first followed by Byooviz. Avastin (C9257) and bevacizumab biosimilars do not require precertification for ophthalmic use. G. CLINICAL INFORMATION (continued)1-866-752-7021 . FAX: 1-888-267-3277 . For Medicare Advantage Part B: Phone: 1-866-503-0857 . FAX: 1-844-268-7263 (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date / / Continuation of therapy: Date of last treatment / / Precertification Requested By: Phone: Fax: A. PATIENT ...MEDICARE FORM. For Medicare Advantage Part B: FAX: 1-844-268-7263. Prolia®, Xgeva® (denosumab) Injectable PHONE: 1-866-503-0857. Medication Precertification Request. For other lines of business: Please use other form. Page 2 of 3. (All fields must be completed and legible for precertification review.)Precertification review for all medications except Cerdelga are handled through Aetna Specialty Precert Unit at 1-866-503-0857 . See also Medical CPB Number: 0442. Policy: Note: The provision of physician samples does not guarantee coverage under the provisions of the pharmacy benefit.1-866-503-0857 . For other lines of business: Please use other form. Note: Abraxane and generic paclitaxel (protein bound) are non-preferred. The preferred products are docetaxel or paclitaxel. Docetaxel and paclitaxel do not require precertification. GR-69491-3 (1-23) Page 1 of 3 (All fields must be completed and legible for precertification ...1-866-752-7021 FAX: 1-888-267-3277 For Medicare Advantage Part B: Phone: 1-866-503-0857 FAX: 1-844-268-7263 Patient First Name . Patient Last Name . Patient Phone . Patient DOB . Breast implant associated anaplastic large cell lymphoma, Cutaneous anaplastic large cell lymphoma, Systemic anaplastic large cell lymphoma (ALCL)Phone: 1-866-503-0857 (TTY: 711) FAX: 1-844-268-7263 For other lines of business: Please use other form. Note: Fylnetra, Nyvepria, Rolvedon, Stimufend, Udenyca and Udenyca Onbody are non-preferred. Fulphila and Neulasta/Neulasta Onpro are preferred. (All fields must be completed and legible for precertification review.) Patient First NameSubject: Multiple Sclerosis. Note: Precertification review for Aubagio, Avonex, Betaseron, Copaxone, Extavia, Gilenya, Glatopa, Lemtrada, Plegridy, Rebif, Tecfidera and Tysabri is handled through Aetna Specialty Precert Unit at 1-866-503-0857. Exception: Member's enrolled in an Individual Plan for the following pharmacy covered drugs - Aubaigo ...Free essays, homework help, flashcards, research papers, book reports, term papers, history, science, politicsProviders can request prior approval using Transdev's PassPORT system or by phone at 866-503-9040. ... 800-526-0857 Voice Users 800-501-0864 TTY Spanish 800-501-0865 Voice Spanish 877-526-6680 American Standard Code for Information Exchange (ASCII) 877-526-6690 Speech-to-Speech (STS)1-866-503-0857 (TTY: 711) For other lines of business: Please use other form. Note: Susvimo is non-preferred. The preferred products are bevacizumab (Avastin) first followed by Byooviz or Eylea/Eylea HD. Avastin (C9257) and bevacizumab biosimilars do not require precertification for ophthalmic use. Precertification Requested By:To pre-certify these drugs call 1-866-503-0857 or fax precertification request form to 1-888-267-3277. ...Exception: Requests for drugs administered by a healthcare professional that will be billed to the medical plan, call 1-866-503-0857 or fax applicable request forms to 1-888-267-3277. Policy: Note: The provision of physician samples does not guarantee coverage under the provisions of the pharmacy benefit.Precertification review for these medications is handled through Aetna Specialty Precert Unit at 1-866-503-0857. For Oral Corticosteroid Clinical policy click here . Policy: Note: The provision of physician samples does not guarantee coverage under the provisions of the pharmacy benefit.1-866-752-7021 acetate for depot suspension) FAX: 1-888-267-3277 Medication Precertification Request For Medicare Advantage Part B: Phone: 1-866-503-0857 Page 2 of 2 FAX: 1-844-268-7263 (All fields must be completed and legible for Precertification Review) Patient First Name . Patient Last Name . Patient Phone . Patient DOB . H. ACKNOWLEDGEMENTPHONE: 1-866-503-0857 (TTY: 711) For other lines of business: Please use other form. Note: Eylea and Eylea HD are non-preferred. The preferred product is bevacizumab (Avastin). Avastin (C9257) and bevacizumab biosimilars do not require precertification for ophthalmic use. (All fields must be completed and legible for precertification review.)Lucentis® (ranibizumab) Injectable Medication Precertification Request. Page 1 of 2. (All fields must be completed and legible for Precertification Review.) For Medicare Advantage Part B: FAX: 1-844-268-7263. PHONE: 1-866-503-0857. For other lines of business: Please use other form. Note: Lucentis is non-preferred.PHONE: 1-866-503-0857 (TTY: 711) For other lines of business: Please use other form. Note: Eylea and Eylea HD are non-preferred. The preferred product is bevacizumab (Avastin). Avastin (C9257) and bevacizumab biosimilars do not require precertification for ophthalmic use. (All fields must be completed and legible for precertification review.)For Medicare Advantage Part B: Phone: 1-866-503-0857 FAX: 1-844-268-7263. G. CLINICAL INFORMATION (continued) - - Required clinical information must be completed in its entirety for all precertification requests. Yes No Was the patient prescribed the requested drug due to clinical worsening after receiving gene replacement therapy (e.g ...Synagis™ (palivizumab ) Note: Precertification review for these medications is handled through Aetna Specialty Precert Unit at 1-866-503-0857. Refer to Medical CPB #0318 Synagis (Palivizumab) Policy: Precertification Criteria. Under some plans, including plans that use an open or closed formulary, Synagis is subject to precertification.MEDICARE FORM. Tremfya® (guselkumab) Medication Precertification Request. Page 2 of 2. (All fields must be completed and legible for precertification review.) For Medicare Advantage Part B: FAX: 1-844-268-7263. PHONE: 1-866-503-0857. For other lines of business: Please use other form.1-866-752-7021 Medication Precertification Request FAX: 1-888-267-3277 Page 2 of 2 For Medicare Advantage Part B: egible for Precertification Review.) Phone: 1-866-503-0857 FAX: 1-844-268-7263 Patient First Name . Patient Last Name . Patient Phone . Patient DOB . G. CLINICAL INFORMATION (continued)503 Sunport Lane, Orlando, FL 32809 Phone: 1-866-503-0857 FAX: 1-888-267-3277 For Medicare Advantage Part B: FAX: 1-844-268-7263 Patient First Name Patient Last Name Patient Phone Patient DOB G. CLINICAL INFORMATION - Required clinical information must be completed in its entirety for all precertification requests.Phone: 1-866-503-0857. For other lines of business: Please use other form. Note: Zoladex is non-preferred. The preferred product is Eligard. Firmagon is also a preferred product. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date / / Continuation of therapy, Date of last treatment(866) 503-0857 Anthem/Blue Cross Blue Shield Phone numbers vary by location; it is best to call the number on the back of the insurance card. Cigna Phone: (800) 244-6224 Fax number for individual drug forms (forms available for download on website): (855) 840-1678 Fax number for the following states: Arkansas,PHONE: 1-866-503-0857 (TTY: 711) For other lines of business: Please use other form. Note: Eylea and Eylea HD are non-preferred. The preferred product is bevacizumab (Avastin). Avastin (C9257) and bevacizumab biosimilars do not require precertification for ophthalmic use. (All fields must be completed and legible for precertification review.)1-866-503-0857 . For other lines of business: Please use other form. Note: Cimzia is non-preferred. Preferred products vary based on indication. See section G below. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date / / Continuation of therapy: Date of last treatment / /1-866-503-0857 . For other lines of business: Please use other form. Note: Xgeva is non-preferred. The preferred products are pamidronate or zoledronic acid. Pamidronate and zoledronic acid do not require precertification. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date:1-866-752-7021 acetate for depot suspension) FAX: 1-888-267-3277 Medication Precertification Request For Medicare Advantage Part B: Phone: 1-866-503-0857 Page 2 of 2 FAX: 1-844-268-7263 (All fields must be completed and legible for Precertification Review) Patient First Name . Patient Last Name . Patient Phone . Patient DOB . H. ACKNOWLEDGEMENT1-866-503-0857 . For other lines of business: Please use other form. Note: Avsola is preferred for MA plans. Preferred status for MAPD plans varies based on indication. See section G below. (All fields must be completed and legible for Precertification Review.) Please indicate: Start of treatment: Start date. Continuation of therapy: Date of ...Synagis™ (palivizumab ) Note: Precertification review for these medications is handled through Aetna Specialty Precert Unit at 1-866-503-0857. Refer to Medical CPB #0318 Synagis (Palivizumab) Policy: Precertification Criteria. Under some plans, including plans that use an open or closed formulary, Synagis is subject to precertification.1-866-503-0857 For other lines of business: Please use other form. Note: Avsola is preferred for MA plans. Preferred status for MAPD plans varies based on indication. See section G. G. CLINICAL INFORMATION (continued) - Required clinical information must be completed in its entirety for all precertification requests. Continued on next pagePhone: 1-866-503-0857 . FAX: 1-844-268-7263 (All fields must be completed and legible for Precertification Review) Please indicate: Start of treatment: Start date / / Continuation of therapy:Date of last treatment / / Precertification Requested By: Phone: Fax: A. PATIENT INFORMATION First Name: Last Name: DOB: Address: City: State: ZIP:1-866-752-7021 . Medication Precertification Request . FAX: 1-888-267-3277 . Page 2 of 2 For Medicare Advantage Part B: Phone: 1-866-503-0857 FAX: 1-844-268-7263 (All fields must be completed and legible for Precertification Review.) Patient First Name . Patient Last Name . Patient Phone . Patient DOB . G. CLINICAL INFORMATION (continued)Prepare 866 503 0857 effortlessly on any device. Online document management has grown to be popular with businesses and individuals. It provides a perfect eco-friendly replacement for traditional printed and signed documents, as you can get the correct form and securely store it online.1-866-503-0857. Or fax applicable request forms to . 1-888-267-3277. 9. Dorsal column (lumbar) neurostimulators: trial or implantation 10. Electric or motorized ...1-866-503-0857 . For other lines of business: Please use other form. Note: Orencia is non-preferred. Preferred products may vary based on indication. See section G below. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment, Start Date: / / Continuation of therapy, date of last treatment:Dental implants. Dialysis visits. When a participating provider initiates request, and dialysis is to be performed at a nonparticipating facility, call 1-866-503-0857. Or fax applicable …The form must be completed by the medical staff and submitted to Aetna in the proper state jurisdiction. Fax: 1 (877) 269-9916. Fax (Specialty Drugs): 1 (888) 267-3277. Aetna Specialty Pharmacy phone: 1 (866) 503-0857. All Aetna Forms.1-866-752-7021 FAX: 1-888-267-3277 . Page 1 of 1 For Medicare Advantage Part B: Phone: 1-866-503-0857 . FAX: 1-844-268-7263 (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment, start date: / / Continuation of therapy,Phone: 1-866-752-7021. FAX: 1-888-267-3277 . For Medicare Advantage Part B: Phone: 1-866-503-0857 . FAX: 1-844-268-7263 (All fields must be completed and legible for Precertification Review.) Please indicate: Start of treatment: Start date . Continuation of therapy: Date of last treatment .GR-68305-3 (9-23) MEDICARE FORM Immune Globulin (IG) Therapy Medication and/or Infusion Precertification Request Page 2 of 3 (All fields must be completed and legible for precertification review.)Note: Precertification review for these medications is handled through Aetna Specialty Precert Unit at 1-866-503-0857. Policy: Precertification Criteria; Under some plans, including plans that use an open or closed formulary, Granix, Leukine, Neulasta, Neupogen, and Zarxio are subject to precertification. If precertification requirements apply ...Specialty Medication Precertification Request - … GR-69374 (2-18)Page 1 of 2 Specialty Medication Precertification Request Aetna Precertification Notification503 Sunport Lane, Orlando, FL 32809 Phone: 1-866-503-0857 FAX: 1-888-267-3277 For Medicare Advantage Part B:FAX: 1-844-268-7263 (All fields must be completed and legible for Precertification Review.)Fasenra® (benralizumab) Injectable Medication Precertification Request. Page 2 of 2. (All fields must be completed and legible for precertification review.) For Medicare Advantage Part B: FAX: 1-844-268-7263 PHONE: 1-866-503-0857 (TTY: 711) For other lines of business: Please use other form. Patient First Name.1-866-503-0857 . For other lines of business: Please use other form. Note: Abraxane and generic paclitaxel (protein bound) are non-preferred. The preferred products are docetaxel or paclitaxel. Docetaxel and paclitaxel do not require precertification. GR-69491-3 (1-23) Page 1 of 3 (All fields must be completed and legible for precertification ...1-866-503-0857 . FAX: 1-844-268-7263 / / / / Patient First Name Patient Last Name . Patient Phone . Patient DOB . G. CLINICAL INFORMATION (continued) – Required clinical information must be completed in its entirety for all precertification requests.Precertification review for these medications is handled through Aetna Specialty Precert Unit at 1-866-503-0857. For Oral Corticosteroid Clinical policy click here . Policy: Note: The provision of physician samples does not guarantee coverage under the provisions of the pharmacy benefit.Drug: Taltz® (ixekizumab) Note: Precertification review for this medication is handled by Aetna Pharmacy Management Precertification at 1-855-240-0535 or fax applicable request forms to 1-877-269-9916. Exception: Requests for drugs administered by a healthcare professional that will be billed to the medical plan, call 1-866-503-0857 or fax applicable request forms to 1-888-267-3277.1-866-503-0857 (All fields must be completed and legible for precertification review) Fax: 1-888-267-3277. For Medicare Advantage Part B: Please Use Medicare Request Form . …. 1-866-503-0857 . For other lines of business: PleaseNote: Precertification review for these me For Medicare Advantage Part B: Phone: 1-866-503-0857 FAX: 1-844-268-7263. G. CLINICAL INFORMATION (continued) – – Required clinical information must be completed in its entirety for all precertification requests. Yes No Was the patient prescribed the requested drug due to clinical worsening after receiving gene replacement therapy (e.g ... 1-866-752-7021 . Medication Precertification Request . F 1-866-503-0857 . For other lines of business: Please use other form. Note: Fulphila, Nyvepria and Ziextenzo are non-preferred. Neulasta/Neulasta Onpro and Udenyca are preferred. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date / / Continuation of therapy: Date of last ...Subject: Multiple Sclerosis. Note: Precertification review for Aubagio, Avonex, Betaseron, Copaxone, Extavia, Gilenya, Glatopa, Lemtrada, Plegridy, Rebif, Tecfidera and Tysabri is handled through Aetna Specialty Precert Unit at 1-866-503-0857. Exception: Member's enrolled in an Individual Plan for the following pharmacy covered drugs - Aubaigo ... 1-866-503-0857 . For other lines of business: Please use ...
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