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 treatment866 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. 23 ratings. 15,005. 10,000,000+ 303. …1-866-503-0857 . For other lines of business: Please use other form . Note: Signifor LAR is non-preferred for acromegaly. The preferred products are Sandostatin LAR and Somatuline Depot. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date . Continuation of therapy, Date of last ...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, ZIPW.) Please indicate: Start of treatment: Start date / / Continuation of therapy: Date of last treatment / For Medicare Advantage Part B: Phone: 1-866-503-0857 FAX: 1-844-268-7263 / Precertification Requested By: Aetna Precertification Notification 503 Sunport Lane, Orlando, FL 32809 Phone: 1-866-752-7021 FAX: 1-888-267-3277 Phone: Fax: A. PATIENT INFORMATION First Name: Last Name: Address ...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 here . Policy: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.1-866-752-7021 . FAX: 1-888-267-3277 . For Medicare Advantage Part B: Phone: 1-866-503-0857 . FAX: 1-844-268-7263 . Page 1 of 3 (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:1-866-752-7021 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. ACKNOWLEDGEMENT503 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.Providers: 866-503-9040 Fax: 630-873-1450. TTY Machine: 630-873-1449 ... 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) 877-826-1130 Voice Carry Over (VCO) Users Non …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 ...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 INFORMATION First Name: Last Name: DOB: Address: City: State: ZIP:Nonverbal communication is possible between culturally different people, but how? Learn about nonverbal communication in this article. Advertisement Let's say that you're traveling...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: 1-866-503-0857 (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 / /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 . 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 ...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 treatment503 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: 1-866-503-0857 FAX: 1-844-268-7263 . Patient First Name . Patient Last Name . Patient Phone . Patient DOB . Reactive Arthritis (Reiter’s syndrome) Yes . Was the treatment with methotrexate ineffective? Please indicate length of therapy: Less than 1 month . 1 month . 2 months . 3 months or greater . No . YesDrug: 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.Phone: 1-866-503-0857 FAX: 1-844-268-7263 . Patient First Name . Patient Last Name . Patient Phone . Patient DOB . Reactive Arthritis (Reiter’s syndrome) Yes . Was the treatment with methotrexate ineffective? Please indicate length of therapy: Less than 1 month . 1 month . 2 months . 3 months or greater . No . YesPage 1 of 1 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: / /.Radicava® (edaravone) Medication Precertification Request. Page 2 of 2. (All fields must be completed and legible for Precertification Review.) Patient First Name. Patient Last Name. Patient Phone. 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 ...Phone: 1-866-752-7021 . FAX: ... 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: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 / /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)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 …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.To pre-certify these drugs call 1-866-503-0857 or fax precertification request form to 1-888-267-3277. ...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 dateDrug: Botox® (onabotulinumtoxinA) Dysport® (abobotulinumtoxinA) Myobloc® (rimabotulinumtoxinB) Xeomin® (incobotulinumtoxinA) Note: Precertification review for these medications is handled through Aetna Specialty Precert Unit at 1-866-503-0857Exception: 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 hereRemicade® (infliximab) Injectable Medication Precertification Request. Page 1 of 5. (All fields must be completed and legible for precertification review.) FAX: 1-844-268-7263. PHONE: 1-866-503-0857. For other lines of business: Please use other form. Note: Remicade is preferred for MA plans. Preferred status for.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 . For other lines of business: Please use other form. Note: Lucentis and Byooviz are non-preferred. The preferred product is bevacizumab (Avastin). Avastin (C9257), Alymsys, Mvasi, and Zirabev do not require precertification for ophthalmic use. (All fields must be completed and legible for precertification review.) Please indicate: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:Aetna Recertification Notification 503 Support Lane, Orlando, FL 32809 Phone: 1-866-503-0857 FAX: 1-888-267-3277 Viscosupplementation Injectable Medication Recertification Request Please indicate: ... 1-866-503-0857 FAX: 1-888-267-3277 Viscosupplementation Injectable Medication Recertification Request Please indicate: We are not affiliated with ...503 Sunport Lane, Orlando, FL 32809. Phone: 1-866-503-0857 . FAX: 1-888-267-3277 . For Medicare Advantage Part B: (All fields must be completed and legible for Precertification Review.) FAX: 1-844-268-7263 Please indicate: Start of treatment: Start date . Continuation of therapy: Date of last treatment . Precertification Requested By: Phone: Fax: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.)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 (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: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.503 Sunport Lane, Orlando, FL 32809. Phone: 1-866-503-0857 . FAX: 1-888-267-3277 . For Medicare Advantage Part B: (All fields must be completed and legible for Precertification Review.) FAX: 1-844-268-7263 Please indicate: Start of treatment: Start date . Continuation of therapy: Date of last treatment . Precertification Requested By: Phone: Fax:Phone: 1-866-752-7021 . 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 . Patient First Name . Patient Last Name . Patient Phone . Patient DOBException: 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 here . Policy:If it is medically necessary for a member to be treated initially with a medication subject to step therapy, the members treating physician may contact the Aetna Pharmacy Management Precertification Unit to request coverage as a medical exception at 1-866-503-0857. (See criteria under section II below). Medical Exception Criteria1-866-752-7021 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)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 / /Remicade® (infliximab) Note: Precertification review for these medications is handled through Aetna Specialty Precert Unit at 1-866-503-0857. Site of Care Utilization Management Policy applies. For information on site of service for Remicade, see Utilization Management Policy on Site of Care for Specialty Drug Infusions at https://www.aetna ...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: Lemtrada is non-preferred. The preferred product is Tysabri for MA plans and Kesimpta for MAPD plans. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date / / Continuation of therapy: Date of last treatmentMEDICARE FORM. Viscosupplementation Injectable Medication Precertification Request. Page 2 of 2. (All fields must be completed and legible for precertification review.) Patient Last Name. Patient Phone. For Medicare Advantage Part B: Phone: 1-866-503-0857 (TTY: 711) FAX: 1-844-268-7263. For other lines of business: Please use other form.Medical Exception Criteria; Aubagio, Avonex, Betaseron, Copaxone 20mg, Extavia, Lemtrada, Plegridy, Tecfidera, and Tysabri are currently listed on the Aetna Formulary Exclusions and Step-Therapy lists.* Therefore, these medications are excluded from coverage for members enrolled in prescription drug benefit plans that use a closed formulary or that require step-therapy criteria, unless a ...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 treatmentMEDICARE FORM Stelara®(ustekinumab) Specialty Medication Precertification Request. 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: Stelara is non-preferred.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.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 / /1-866-752-7021 . 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:FAX: 1-844-268-7263. For other lines of business: Please use other form. Note: Daxxify, Dysport and Myobloc are non-preferred. The preferred products are Botox and Xeomin. Precertification Requested By: A. PATIENT INFORMATION.PHONE: 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 / /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: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 otherHow to get started. We have several ways for you to fill a prescription through the network specialty pharmacy. New prescriptions: For a new prescription, your doctor can: e-Prescribe NCPDP ID 1466033. Fax your prescription to 1-800-323-2445. Call us at 1-800-237-2767.: 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 ...Video instructions and help with filling out and completing 866 503 0857 Form. Find a suitable template on the Internet. Read all the field labels carefully. Start filling out the blanks according to the instructions: Instructions and help about aetna prior authorization form for prolia.503 Sunport Lane, Orlando, FL 32809. Phone: 1-866-503-0857 . FAX: 1-888-267-3277 . For Medicare Advantage Part B: (All fields must be completed and legible for Precertification Review.) FAX: 1-844-268-7263 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: 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 ...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-Medicare pharmacy (oral drugs): 1-855-240-0535 ${tty}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 . Patient First Name . Patient Last Name . Patient Phone . Patient DOB . G. CLINICAL INFORMATION (continued)MEDICARE FORM. Viscosupplementation Injectable Medication Precertification Request. Page 2 of 2. (All fields must be completed and legible for precertification review.) Patient Last Name. Patient Phone. For Medicare Advantage Part B: Phone: 1-866-503-0857 (TTY: 711) FAX: 1-844-268-7263. For other lines of business: Please use other form.. The PeopleFinders phone number lookup gives you all the informat1-866-752-7021 Medication Precertification Request FAX: 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 ...1-866-752-7021 . 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 ... PHONE: 1-866-503-0857 (TTY: 711) For other lines of busi 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) 1-866-503-0857 . For other lines of business: Please use other for...
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