Form Aetna Pharmacy
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Plan for your best health
fm.formularynavigator.com• Call the Aetna Pharmacy Precertification Unit: Non-Specialty 1-800-294-5979 or Specialty 1-866-814-5506. • Fax the completed request form to: Non-Specialty 1-888-836-0730 or Specialty 1-866-249-6155. • Mail the completed request form to: Aetna Pharmacy Management 1300 East Campbell Road Richardson, TX 75081
Aetna Pharmacy Manage ment Drug Claim Form PO Box …
member.aetna.comDrug Claim Form Mail completed form with receipts: Aetna Pharmacy Manage ment PO Box 52446 Phoenix, AZ 85072-2446 . When you submit: • Do not staple or tape receipts to this form. Keep all attachments separate. • Include pharmacy receipt, (not the cash receipt ). Pharmacy receipts are usually attached to the bag
Pharmacy Prior Authorization Request Form - Aetna
www.aetnabetterhealth.comPharmacy Prior Authorization Request Form. 6. Is there any additional information the prescribing provider feels is important to this review? Please specify below or submit medical records. For example, explain the negative impact on medical condition, safety issue, reason formulary agent is not suitable to a specific medical
Medical Exception/ Fax this form to: 1-877-269 ... - Aetna
www.aetna.comAetna 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, Coventry Health Care plans and their affiliates (Aetna). GR-69164 (9-16) OR Page 3 of 10
Prior authorization request form - Aetna
www.aetnabetterhealth.comAetna Better Health®of Pennsylvania Aetna Better Health® Kids 2000 Market Street, Suite 850 Philadelphia, PA 19103 . Prior authorization request form . You must have a valid PROMISe ID (i.e., participate in the Pennsylvania Medicaid programs) at the time the service is rendered in order for your claim to be paid.
MEDICARE FORM Viscosupplementation Injectable - Aetna
www.aetna.comMEDICARE FORM Viscosupplementation Injectable Medication Precertification Request Page 2 of 2 (All fields must be completed and legible for precertification review.) For Medicare Advantage Part B: PHONE: 1-866-503-0857 FAX: 1-844-268-7263 For other lines of business: Please use other form. Note: Durolane, Euflexxa, Gel-One, Gelsyn-3, GenVisc,
MAIL ORDER PHARMACIES - Cigna
www.cigna.comPharmacy Contact Information Plan Contact Information . Cigna-HealthSpring Rx . Preferred Network Pharmacies . If you have any questions, please contact Stand-Alone Part D Postal Prescription Services (PPS) Èð (800) 552-6694 (TTY 711) us at 1-800-222-6700 (TTY 711), 8:00
Aetna Rx Home Delivery
member.aetna.comAetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a subsidiary of Aetna Inc., a licensed pharmacy providing mail-order pharmacy services. Aetna’s negotiated charge with Aetna Rx Home Delivery may be higher than Aetna Rx Home Delivery’s cost of purchasing drugs and providing mail-order pharmacy services.
AFA Administrative Handbook - Aetna
lp.aetna.comAetna 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). Welcome! Thank you for choosing the Aetna Funding Advantage self-insured health plan — you made a great choice.
Formulary Exception/Prior Authorization Request Form
www.caremark.com2. Has the requested drug been dispensed at a pharmacy and approved for coverage previously by a prior plan? Yes or No 3. How long has the patient been on the requested medication? Is the requested product being used for an FDA-approved indication or an indication supported in the compendia of current literature (examples: AHFS, Micromedex,
Aetna - Medical Exception/Prior Authorization ...
www.aetna.comThis pre-authorization request form should be filled out by the provider. Before completing this form, please confirm the patient’s benefits and eligibility.