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GR-69025-1 CO (10-14) Fax this form to: 1 -877 269 9916 For specialty drugs fax to: 1-888-267-3277Drug: 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 1-888-267-3277.1-866-752-7021 . 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, Date of last treatment / / Precertification Requested By: Phone: Fax:Alirocumab (PraluentTM) Injectable Medication Precertification Request. Aetna Precertification Notification 503 Sunport Lane, Orlando, FL 32809 Phone: 1-866-503-0857. Page 1 of 2. FAX: 1-888-267-3277. (All fields must be completed and legible for precertification review) For Medicare Advantage Part B: FAX: 1-844-268-7263.Pharmacy: 866-503-0857; Infusions *For any tests other than those listed call the health plan directly to verify authorization requirements. ... NIA (National Imaging Associates): 866-842-1767/ Prefix WMW thru AIM: 866-688-1449 ; MRI/MRA, CT/CTA, PET, Nuclear Cardiology, All Types of Echos, Infusions *For any tests otherThe 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.: 1-866-503-0857 . FAX: 1-844-268-7263 . For other lines of business: Please use other form. Note: Aralast NP, Glassia and Zemaira are non-preferred. The preferred product is Prolastin-C. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date . Continuation of therapy: Date of ...For help finding transportation, contact Transdev at: Participants call 877-725-0569. Providers call 866-503-9040. 2. Participants or Providers should call Transdev to request authorization for a trip. Please have the following information ready: a. Participant date of birth, first and last name, and phone number. b.Spinraza® (nusinersen) Injectable Precertification Request. Page 1 of 4. (All fields must be completed and legible for precertification review.) Phone: 1-866-752-7021 FAX: 1-888-267-3277. For Medicare Advantage Part B: 1-866-503-0857. Start of treatment: Start date Continuation of therapy: Date of last treatment / /.Member is ≥12 years of age and weighs at least 77 pounds (35 kilograms), AND. A documented diagnosis of hepatitis C Genotype 1, AND. Member is treatment-naïve without cirrhosis or with compensated cirrhosis (Child-Pugh A) - Max Time of Approval 12 weeks (84 tablets total), OR.If you received this transmission in error, please notify us immediately by telephone at (866) 503-0857. GR-69377 (5-18) Title: Diabetic Testing Supplies Prior Authorization Request Form Author: CQF Subject: Accessible - Diabetic …Medicare pharmacy (injectable drugs): 1-866-503-0857 ${tty} Non-Medicare plans (includes individual & family plans): 1-888-632-3862 ${tty}, (choose precertification prompt) Non …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.Free essays, homework help, flashcards, research papers, book reports, term papers, history, science, politics1-866-503-0857. Or fax applicable request forms to . 1-888-267-3277. 9. Dorsal column (lumbar) neurostimulators: trial or implantation ... For the followingservices,providers call1-866-503-0857orfax applicable request forms to 1-888-267-3277,withthe following exceptions: • Forprecertificationof pharmacy -coveredspecialtydrugs(notedwith ...Pulmonary Hypertension (Inhalation or 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. For other lines of business: Please use other form.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. G. CLINICAL INFORMATION (continued) – Required clinical information must be completed in its entirety for all precertification requests. For Initiation requests:Prepare 866 503 0857 effortlessly on any device. Online document managing has grown to be more popular with enterprises and individuals. It provides a perfect eco-friendly replacement for conventional printed and signed paperwork, since you can find the proper form and securely store it online.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 ...(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,Drug: Cosentyx® (secukinumab) 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 1-888-267-3277Please indicate: Start of treatment: Start date / / Continuation of therapy, Date of last treatment. Precertification Requested By: / / Phone: 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: Zoladex is non-preferred. The preferred product is Eligard.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:Diabetic Testing Supplies Prior Authorization Request Form Ph: (866) 503-0857 Fax: (877) 269-9916 . MEMBER INFORMATION Member name . Member ID . Member Address, City, State, ZIPAetna Precertificatio n Notification 503 Sunport Lane Orlando FL 32809 Phone 1-866-503-0857 FAX 1-888-267-3277 Hepatitis C Treatment Medication Precertificatio n. Fill Now. If you believe that this page should be taken down, please follow our DMCA take down process here. ...According to the CIA, as of 2018 there were an estimated 981,129,427 boys ages 0 to 14 living in the world. This number stems from an estimated total population of 7,503,828,180. Y...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 ...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: / /.Diabetic Testing Supplies Prior Authorization Request Form Ph: (866) 503-0857 Fax: (877) 269-9916 . MEMBER INFORMATION Member name . Member ID . Member Address, City, State, ZIPPHONE: 1-866-503-0857 (TTY: 711) For other lines of business: Please use other form. Note: Lupron Depot is non-preferred. The preferred product Page 1 of 3 is Eligard. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date / / Continuation of therapy, Date of last treatment / /Aetna Specialty Pharmacy phone: 1 (866) 503-0857. All Aetna Forms. Does Aetna Medicare PPO require referrals? Aetna Medicare PPO Prime plans PCP referrals are not required. Patients receiving covered services from a nonparticipating provider are subject to out-of-network deductibles and coinsurance and to potential balance billing.866 503 0857. Get the up-to-date GR 68722 Medication Precertification Form - Aetna 2024 now Get Form. 4.4 out of 5. 215 votes. DocHub Reviews. 44 reviews. DocHub Reviews.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 ...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 . Patient First Name . Patient Last Name . Patient Phone . Patient DOB . G. CLINICAL INFORMATION (continued)The 1950s Classic Henry J Cars Channel covers popular antique Henry Js from the decade. Take a look under the hood of 1950s classic Henry J cars. Advertisement The 1950s Classic He...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.Osteoporosis Injectable Medication. Recertification Request. Aetna Recertification Notification. 503 Support Lane, Orlando, FL 32809. Phone: 1-866 -503-0857 ...Osteoporosis Injectable Medication. Recertification Request. Aetna Recertification Notification. 503 Support Lane, Orlando, FL 32809. Phone: 1-866 -503-0857 ...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 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 Non-Medicare Prescription Drug Plan. 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 ...Vimizim®(elosulfase alfa) Medication Precertification Request. (All fields must be completed and legible for Precertification Review.) Aetna Precertification Notification 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. Please indicate: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)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.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 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. Yes1-866-752-7021 . 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 .1-866-503-0857 . For other lines of business: Please use other form . Note: Procrit and Epogen are non-preferred. The preferred products are Aranesp and Retacrit. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date / / Continuation of therapy: Date of last treatment / /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 . Please indicate: Start of treatment: Start date Continuation of therapy: Date of last treatment . Precertification Requested By: Phone: Fax: A. PATIENT INFORMATION .Phone: 1-866-503-0857 FAX: 1-888-267-3277 For Medicare Advantage Part B: Phone: 1-866-503-7021 FAX: 1-844-268-7263 G. CLINICAL INFORMATION (Continued) - Required clinical information must be completed in its entirety for all precertification requests. Please indicate which eye the treatment is being requested for?1-866-503-0857 For other lines of business: Please use other form. Note: Entyvio is preferred on MA and MAPD plans. / / Continued on next page G. CLINICAL INFORMATION (continued) – Required clinical information must be completed in its entirety for all precertification requests.Drug. Rituxan® (rituximab) Note: 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.Precertification Request Aetna Precertification Notification . 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 ...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 / / Patient First Name . Patient Last Name . Patient Phone . Patient DOB . G. CLINICAL INFORMATIONPhone: 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 . G. CLINICAL INFORMATION (Continued) - Required clinical information must be completed for ALL precertification requests.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 / / Precertification Requested By: Phone: Fax: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: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.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. For Oral Corticosteroid Clinical policy click here1-866-752-7021 . Sandostatin, Sandostatin LAR Depot . FAX: 1-888-267-3277 . or Bynfezia Pen . For Medicare Advantage Part B: Phone: 1-866-503-0857 . Medication Precertification Request . FAX: 1-844-268-7263 . Page 3 of 3 (All fields must be completed and legible for precertification review) - Patient First Name . Patient Last Name . Patient ...Aetna Precertification Notification 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. Precertification ......