Search results with tag "Medication precertification request"
Otezla® (apremilast) Medication Precertification Request
www.aetna.comOtezla® (apremilast) Medication Precertification Request Page 2 of 2 (Please complete all fields and return both pages for precertification review) Aetna Precertification Notification
Ocrevus® (ocrelizumab) Medication Precertification Request
www.aetna.com(ocrelizumab) Medication Precertification Request . Page 2 of 2 (All fields must be completed and return all pages for precertification review) 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 . Patient First Name . Patient Last Name . Patient ...
Remicade® (infliximab) Injectable Medication ...
www.aetna.comMedication Precertification Request Page 3 of 8 (All fields must be completed and legible for precertification review.) Aetna Precertification Notification Phone: 1-866-752-7021 FAX: 1-888-267-3277 For Medicare Advantage Part B: Please Use Medicare Request Form
Specialty Medication Precertification Request - aetna.com
www.aetna.comGR-69374 (2-18) Page 1 of 2 Specialty Medication Precertification Request Aetna Precertification Notification 503 Sunport Lane, Orlando, FL 32809
Rituxan® (rituximab) Medication Precertification Request
www.aetna.comGR-68535 (5-18) Page 1 of 3 Continued on next page Rituxan® (rituximab) Medication Precertification Request Aetna Precertification Notification 503 Sunport Lane, Orlando, FL 32809
Avonex® (interferon beta-1a) Medication Precertification ...
www.aetna.comAvonex ® (interferon beta-1a) Medication Precertification Request . Aetna Precertification Notification. Phone: 1-855-240-0535 . FAX: 1-877-269-9916
Xeloda® (capecitabine) Oral Medication Precertification ...
www.aetna.comGR-69130 (8-18) Xeloda ® (capecitabine) Oral Medication Precertification Request . Page 1 of 3 . Aetna Precertification Notification 503 Sunport Lane, Orlando, FL 32809
Feraheme® (ferumoxytol) and Injectafer® (ferric ...
www.aetna.com(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
Darzalex™ (daratumumab) Medication …
www.aetna.comDarzalex TM (daratumumab) Medication Precertification Request Page 2 of 2 (All fields must be completed and return both pages for precertification review)
Tysabri® (natalizumab) Medication Precertification Request
www.aetna.comThe patient has worsening disability (sustained worsening of Expanded Disability Status Scale (EDSS) score or neurological examination findings) Other (please explain):
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