866-503-0857
Pediatric Growth Hormone Injectable Medication Precertification Request Aetna Precertification Notification 503 Sunport Lane Orlando FL 32809 Phone 1-866-503-0857 FAX 1-888-267-3277 Page 1 of 2 Please return Pages 1 and 2 for precertification of medications. Please indicate Start of treatment Start date / Continuation of therapy Date of lastPHONE: 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.)
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1-866-503-0857 . For other lines of business: Please use other form. Note: Abraxane is non-preferred. The preferred products are docetaxel or paclitaxel. Docetaxel and paclitaxel do not require precertification. (All fields must be completed and legible for Precertification Review.) Please indicate: Start of treatment: Start date / /1-866-503-0857 . or fax applicable request forms to . 1-888-267-3277, with the following exceptions: • For precertification of pharmacy-covered specialtydrugs (noted with*) when memberis enrolled in a commercial plan, call . 1-855-240-0535 . or fax applicable request forms to . 1-877-269-9916 • Providers can use the drug-specific503 Sunport Lane, Orlando, FL 32809. Medication Precertification Request. 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: Please indicate: Start of treatment: Start date / / FAX: 1-844-268-7263 Continuation of therapy: Date of last ...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:Phone: 1-866-503-0857 (TTY:711) VPRIV ® (velaglucerase alfa) FAX: 1-844-268-7263 . For other lines of business: Medication Precertification Request. Please use other form. Page 2 of 2 Note: Vpriv is non-preferred. The (All fields must be completed and legible for Precertification Review.) preferred products are Cerezyme and Elelyso. Patient ...Who is calling or texting from 866-503-0857 phone number? Reverse Phone Lookup registered owner's full name, address, public records & background check for +1 866-503-0857 with Whitepages.Page 2 of 2. (All fields must be completed and legible for precertification review.) Patient First Name. Patient Last Name. Patient 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: Simponi Aria is preferred for MA plans and non-preferred for MAPD plans.Policy: Precertification Criteria; Under some plans, including plans that use an open or closed formulary, Intravenous Immunoglobulins (IVIG) and Adagen are subject to Precertification. If Precertification requirements apply Aetna considers these medications to be medically necessary for those members who meet the following precertification criteria: (see also Appendix A)De wijkraad zetelt in de Blinkert en voorlichtingsavonden of het stembureau vinden bijna als vanzelfsprekend op deze locatie plaats. Bij De Blinkert staan 75 aanleunwoningen. De …PHONE: 1-866-503-0857 . Simponi Aria ® (golimumab) Infusion 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 . For other lines of business: please use other form. Note: Simponi Aria is preferred for MA plans and non ...859-455-8650. CoverMyMeds - Pre-Authorization. 866-503-0857. CoverMyMeds - General Information. 866-452-5017. Aetna Coventry (Workers Compensation and Auto Injury) 800-937-6824. Discover Aetna provider phone numbers. Simplify interactions and access support promptly with accurate and up-to-date contact information.PHONE: 1-866-503-0857 (TTY: 711) For other lines of business: Please use other form. Note: Lucentis and Cimerli are 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. Patient First Name1-866-752-7021 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 INFORMATIONPrecertification 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.1-844-268-7263. 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 For other lines of business: Please use other form. Note: Granix is non preferred. Zarxio is preferred. 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.
The form must be completed by the medical staff and submitted to Aetna in the proper state jurisdiction. Fax: 1 (877) 269 …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)PHONE: 1-866-503-0857 For other lines of business: please use other form. Note: Nivestym is non preferred. Zarxio is preferred. 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.1-866-503-0857 . For other lines of business: Please use other form. Note: Entyvio is preferred on MA plans. On MAPD plans Entyvio is preferred for ulcerative colitis and non-preferred for Crohn’s disease. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date / /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.)
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. Note: Lucentis and Cimerli are non- preferred. The preferred products are bevacizumab (Avastin) first followed by Byooviz or Eylea/Eylea HD. Avastin (C9257) and bevacizumab biosimilars do not require ...1-866-503-0857 . For other lines of business: Please use other form. Note: Tremfya is non-preferred. Preferred products vary based on (All fields must be completed and legible for precertification review.) indication. See section G below. Please indicate: Start of treatment: Start date / / Continuation of therapy: Date of last treatment / /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 Name…
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PHONE: 1-866-503-0857 (TTY: 711) For other lines of business: Please use other form. Note: Feraheme, Injectafer, and Monoferric are non-preferred. The preferred products are Ferrlecit (sodium ferric gluconate), Infed, and Venofer. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start dateGR-69025-1 CO (10-14) Fax this form to: 1 -877 269 9916 For specialty drugs fax to: 1-888-267-3277
1-866-503-0857 . For other lines of business: Please use other form . Note: Epogen and Retacrit are non-preferred. The preferred products are Aranesp and Procrit. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date . Continuation of therapy: Date of last treatmentPhone: 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. Yes
Phone: 1-866-503-0857 (TTY: 711) FAX: 1-844-268-726 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: 1-866-752-7021 . Sandostatin, Sandostatin LAR Depot . F1-866-503-0857 . For other lines of business: Ple PHONE: 1-866-503-0857 . For other lines of business: Please use other form . Note: Trelstar 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 treatment1-866-752-7021 . 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: Aetna Precertification Notification 503 Su GR-69025-CA (10-14) Page 1New 08/13 of 2 PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM Instructions: Please fill out all applicable sections on both pages completely and legibly . Attach any additional documentation that is: 1-866-503-0857 For other lines of business: Please use other form Note: Cinqair is non-preferred. The preferred products are Nucala and Xolair. G. CLINICAL INFORMATION (continued) - Required clinical information must be completed in its entirety for all precertification requests. / / Patient First Name . Patient Last Name . Patient Phone 1-866-503-0857 . For other lines of business1-866-752-7021 Injectable PrecertificatiIf it is medically necessary for a member to 503 Sunport Lane, Orlando, FL 32809 . 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 / /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. Note: Lucentis and Cimerli are non- preferred. The preferred products are bevacizumab (Avastin) first followed by Byooviz or Eylea/Eylea HD. Avastin (C9257) and bevacizumab biosimilars do not require ... For Medicare Advantage Part B: Phone: 1-866-503-0857 PHONE: 1-866-503-0857 . For other lines of business: Please use other form. Note: Botox and Myobloc are non-preferred. The preferred products are Dysport and Xeomin. Tags: Aetna, Medication, Request, Precertification, Injectable, Toxins, Botulinum, Botulinum toxins injectable medication precertification request, Dysport.PHONE: 1-866-503-0857 . For other lines of business: Please use other form . Note: Trelstar 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 1-866-752-7021. FAX: 1-888-267-3277 . For Medicare Advant[1-866-503-0857 For other lines of business: Pleas1-866-503-0857 (TTY: 711) For other lines of bu 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.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: