Aetna Prior Authorization Form

Aetna Medicaid Prior-Authorization List for Participating ...

Aetna Medicaid Prior-Authorization List for Participating Providers Effective July 1, 2008 Aetna Medicaid Prior-Authorization List for participating providers for 2008: Applies to: Aetna Medicaid and CHIP This 2008 Prior-Authorization List supersedes all previous lists from Aetna Medicaid and ...

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SM Aetna Better Health Provider Connection - etna Better Health

the provider must get prior authorization from Aetna Better Health before a pharmacy can fill the prescription. Complete the Non-Formulary Request Form and fax it to Aetna Better Health’s Prior Authorization department at 1-877-309-8077.

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REQUEST FOR PRIOR AUTHORIZATION

Please check Health Plan O Aetna O Cigna O Aetna Golden Medicare Plan O Health Net O Blue Shield 65 Plus O Health Net Seniority Plus O Blue Shield Access Plus O PacifiCare O ... it is recommended that you do not schedule appointments prior to authorization ... (See reverse side of this form) ...

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USE FOR MEDICARE DRUG PLAN PARTICIPANTS ONLY

USE FOR MEDICARE DRUG PLAN PARTICIPANTS ONLY Medical Exception/Precertification* Request for Prescription Medications For FASTEST service, Call 1-800-414-2386 Monday-Friday, 8 a.m. to 5 p.m. - local time Continental U.S. Fax to: 1-800-408-2386 or email: https://www.aetna.com/provweb/ Visit www ...

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Aetna Prior Auth Form

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Drugs Covered Uses

PRIOR AUTHORIZATION CRITERIA Drugs Covered Uses Exclusion Criteria Required Medical Information Age Restrictions Prescriber Restrictions Coverage Duration Other Criteria ADCIRCA All FDA approved indications not otherwise excluded from Part D. Member is NOT concurrently on organic nitrates (for ...

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Medication Request

... UPON RECEIPT OF THIS FORM, AETNA SPECIALTY PHARMACY WILL VERIFY BENEFITS AND CONTACT MEMBERS BY TELEPHONE TO CONFIRM DELIVERY OF COVERED PRESCRIPTIONS ... please provide the following ship and bill authorization information before faxing in this form: Ship and Bill Authorization Contact Name: ...

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REQUEST FOR PRIOR AUTHORIZATION

O Aetna O Cigna O Secure Horizons O Aetna Golden Medicare Plan O Health Net O Blue Shield 65 Plus O Health Net Seniority Plus O Blue Shield Access Plus O Humana Medicare Advantage O California Care O PacifiCare OBreastfeeding Medicine Referral O O O O ONutrition Consult for Chronic Disease (CMC ...

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Insurance Contacts for Pre-authorization

AETNA: Preauthorization needed for all Cat Scan, MRI/MRA and Nuclear Med Cardiac exams. ... Anthem Smart Value Plans do not require prior authorization.

westerlyhospital.org

PHARMACY PRIOR AUTHORIZATION Clinical Guideline Savella ...

AETNA BETTER HEALTH IN PENNSYLVANIA Last Review: 04/2010 PA-10-04-12 PHARMACY PRIOR AUTHORIZATION Clinical Guideline Savella ® (milnacipran) FDA Indication Fibromyalgia Dosage Forms 12.5 mg, 25 mg, 50 mg, 100 mg tablets Dosage Adults and Adolescents > 17 years: 12.5 mg once on day 1, then 12.5 ...

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