Infertility Services Precertification Information …
Page 1 of 5 PCFXInfertility ServicesPrecertification Information Request FormApplies to:Aetna plansInnovation Health plansHealth benefits and health insurance plans offered, underwritten and/oradministered by the following:Allina Health and Aetna Health Insurance Company (Allina Health | Aetna)Banner Health and Aetna Health Insurance Company and/or Banner Health and Aetna Health Plan Inc. (Banner | Aetna)Sutter Health and Aetna Administrative Services LLC (Sutter Health | Aetna)Texas Health + Aetna Health Plan Inc. and Texas Health + Aetna Health InsuranceCompany (Texas Health Aetna)Aetna is the brand name used for products and Services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna).
Infertility Services Precertification Information Request Form Page 3 of 4 GR-69375 (5-18) V1 Fax to: Infertility Department. Fax number: 1-866-488-9429
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