Transcription of Feraheme Injectafer Precert Request - Aetna
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Feraheme Injectafer Precert Request - Aetna
GR-69574 (7-20)Page 1 of 2 / / // _____ Continued on next pageFeraheme (ferumoxytol) and Injectafer (ferric carboxymaltose) Medication Precertification Request 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 Requested By: Phone: Fax: A. PATIENT INFORMATIONF irst Name:Last Name: DOB: Address: City: State: ZIP:Home Phone: Work Phone: Cell Phone:Email: Patient Current Weight: lbs orkgs Patient Height: inches orcms Allergies: B.
Please indicate the patient’s serum ferritin level: Please indicate the patient’s transferrin saturation (TSAT) level: Yes. No. Was the serum ferritin and/or transferrin saturation level drawn within the last 30 days? Yes . No. Is this a request for continuation of therapy? Yes . No
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