Aetna - Medical Exception/Prior Authorization ...
New Therapy . Renewal . If Renewal, Date therapy initiated: Route of administration: Oral/SL . Topical . Injection . IV . Other: Administered: Doctor’s Office . Dialysis Center. Home Health . By Patient . Other: Medication Name Dose/Strength . Frequency Length of Therapy Number of Refills Quantity ; List of Previous Drugs Tried Drug Name; Dosage
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• Accu Reference Medical Laboratory, LLC • Advanced Clinical Laboratory Solutions, Inc. • Alere Toxicology • Ameritox • ARL/Labsouth, Inc.
Coverage of Experimental and Investigational Procedures Policy Aetna covers experimental or investigational technologies (i.e., …
September 2017 Aetna OfficeLink Updates™ All regions Inside this issue Updates to our precertification list 2 Clinical payment, coding and policy updates 3 – 4
Custom Medicare HMO Open Access Plan State of New Jersey PLAN DESIGN AND BENEFITS Aetna Medicare SM Plan (HMO) PROVIDED BY AETNA HEALTH INC Arizona, California, Connecticut, Delaware, District of Columbia, Florida, Georgia, Illinois, Maryland, Maine, New
PCFX . Ptosis Surgery Precertification Information Request Form . About this form . You can’t use this form to initiate a precertification request.
When initiating NEW diabetes therapy using monotherapy or combination medications: Adding Medication Observation Time Group A ONLY 14 days Group B-D 30 days Group E1 60 days . When ADDING a new medication to an ESTABLISHED TREATMENT regimen: Current Medication Adding Medication Observation Time on Group A-D + new Group A-D 14 days
Behavioral Therapy (CBT), CBT for Anxiety • Medication Option(s): SSRIs and venlafaxine Insomnia • Psychotherapy Treatment Option(s): Cognitive Behavioral Therapy for insomnia (CBT-I) is highly effective. Other forms of CBT may be helpful. • Medication Option(s): low dose trazodone,prazosin, amitriptyline, doxepin, or diphenhydramine
medication, include what the child reports regarding the benefits and side effects of having taken the medication. The child will provide input on the medication being prescribed (check all that apply): The caregiver will provide input on the medication being prescribed (check all that apply): e. a. f. d. Through the social worker/probation ...
Individual therapy to help Jill learn and implement coping skills and to help her identify, process and resolve feelings and concerns. 2. Jill Spratt 3. Responsible Person(s): Tom Thumb, Ph.D. 1. Intervention/actions: Family Therapy to provide psycho-education about depression to increase parents’ insight into Jill, and to