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 (TTY: 711) (commercial) or : 1-866-503-0857 (TTY: 711) (Medicare). *Availity is available only to U.S. providers and its territories. The Aetna Premier Care Network Plus program is now multi-tiered : Starting January 1, some of your patients might be in our new Aetna Premier Care Network PlusRemicade® (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.1-866-503-0857 . For other lines of business: Please use other form. Note: Entyvio is preferred on MA (All fields must be completed and legible for precertification review.) and MAPD plans. 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: Renflexis 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 / /Note: Precertification review for Eylea, Lucentis, and Macugen 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, Cystaran, Eylea, Jetrea, Lucentis, Macugen, Ozurdex, Visudyne is subject to precertification. If ...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 page1-866-752-7021 . 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 ...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.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.1-866-503-0857 . For other lines of business: Please use other form. Note: Ilumya 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 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 (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: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: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.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: 1-866-503-0857 (TTY:711) FAX: 1-844-268-7263 . For other lines of business: Please use other form . Note: Epogen, Jesduvroq and Retacrit are non-preferred. The preferred products are Aranesp and Procrit. Page 1 of 3 (All fields must be completed and legible for precertification review.) Please indicate: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: Address: City: ...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)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.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)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.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.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 Please indicate: Start of treatment: Start date / / Continuation of therapy: Date of last treatment / / Precertification Requested By: Phone: Fax: A. PATIENT 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 in its entirety for all precertification requests. YesMEDICARE 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.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 / /To initiate precertification or inquire about pending precertification, call an Aetna representative toll free at 1-866-503-0857. Next-day delivery Complete orders received before 3 p.m. ET are scheduled for next-day delivery.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: / /.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)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)Free essays, homework help, flashcards, research papers, book reports, term papers, history, science, politicsPhone: 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 INFORMATIONDrug: Otezla® (apremilast) 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 . For other lines of business: Please use other form. Note: Inflectra 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 / /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.1-866-503-0857 . For other lines of business: Please use other form. Note: Stelara is non-preferred. Preferred products vary based on indication. See section G below. (Please return. Pages 1 to 3. for precertification of medications.) Please indicate: Start of treatment: Start date . Continuation of therapy: Date of last treatment ...For precertification of adalimumab (Humira), call (866) 752-7021 (Commercial), (866) 503-0857 (Medicare), or fax (888) 267-3277. Is there a biosimilar to Humira? The FDA has approved a seventh adalimumab biosimilar, Yusimry (CHS-1420) developed by Coherus BioSciences. The product references Humira, a tumor necrosis factor blocker, and was ...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 page1-866-503-0857 . 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 ...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.Fulvestrant Injection: learn about side effects, dosage, special precautions, and more on MedlinePlus Fulvestrant injection is used alone or in combination with ribociclib (Kisqali...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 . 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 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,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) 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 NameNote: 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 ...1-866-503-0857 . For other lines of business: Please use other form. Note: Inflectra 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 / /The Wells Fargo Visa Signature card has a few features that are truly uncommon for a no-annual-fee product. You don't even have to use it regularly to reap its benefits. Update: Th...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 (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)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 - Required clinical information must be completed in its entirety for all precertification requests.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 . 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: 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.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 ...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. .... Feb 3, 2010 · Reverse phone lookup for (866) 503-0857. Find full nam1-866-503-0857 . For other lines of busine DEKABANK DT.GIROZENTRALESTUFENZINS-ANLEIHE 18(24) (DE000DK0N452) - All master data, key figures and real-time diagram. The DekaBank Deutsche Girozentrale-Bond has a maturity date o...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) Fasenra® (benralizumab) Injectable Medication Prec 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 ... 1-866-503-0857 . For other lines of business: Ple...
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