Transcription of ) Injectable Medication Precertification Request - Aetna
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) Injectable Medication Precertification Request - Aetna
MEDICARE FORM Prolia , Xgeva (denosumab) Injectable Medication Precertification Request Page 1 of 3 For Medicare Advantage Part B: FAX: 1-844-268-7263 PHONE: 1-866-503-0857 For other lines of business: Please use other form. Note: Xgeva is non-preferred. The preferred product is 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: / / 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: Current Weight: lbsor kgsHeight: inchesor cms Allergies: B.
MEDICARE FORM Prolia®, Xgeva® (denosumab) Injectable Medication Precertification Request Page 1 of 3 For Medicare Advantage Part B: FAX: 1-844-268-7263 . PHONE: 1-866-503-0857 . For other lines of business:
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