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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 / /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: Vabysmo is non-preferred. The preferred products are bevacizumab (Avastin) first followed by Byooviz or Eylea/Eylea HD.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 ...

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: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.Repository (H.P. Gel) Aetna Recertification Notification 503 Support Lane Orlando, FL 32809 Phone: 1-866-503-0857 FAX: 1-888-267-3277 Medication Recertification Request (All fields must be completed. We are not affiliated with any brand or entity on this form. 4,4. 98,753 Reviews. 4,5. 11,210 Reviews. 4,6.1-866-503-0857. For other lines of business: Please use other form. Note: Granix, Leukine, Neupogen, Nivestym, and Releuko are non-preferred. Zarxio is preferred. (All fields must be completed and legible for precertification review.) 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, ZIPPharmacy: 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 other ….

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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: 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) 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)

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 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: A. PATIENT INFORMATION

balance sheet wileyplus (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,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. 9911 w pico blvdintegrity motorsports liberal ks 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 ... kettering health network employee portal 1-866-503-0857 . For other lines of business: Please use other form. Note: Lucentis is non-preferred. The preferred product is bevacizumab (Avastin). Avastin (C9257), Mvasi, and Zirabev do not require precertification for ophthalmic use. (All fields must be completed and legible for Precertification Review.) Please indicate: Start of treatment ... jamie lynn scott south carolinacommit 30 coupon codessays informally nyt 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.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) trempealeau county mugshots Precertification review for this medication is handled through Aetna Specialty Precert Unit at 1-866-503-0857 Refer to Medical CPB #0807 Eculizumab (Soliris) Site of Care Utilization Management Policy applies. For information on site of service for Soliris, ... harrison county wv 911 logmarine creature four consecutive vowelsrest areas near atlanta ga 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: 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 ...