866-503-0857

1-866-503-0857 . For other lines of business: Please use other form. (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 INFORMATION First Name:

1-866-752-7021 FAX: 1-888-267-3277 . Page 1 of 1 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,(866) 503-0857 Anthem/Blue Cross Blue Shield Phone numbers vary by location; it is best to call the number on the back of the insurance card. Cigna Phone: (800) 244-6224 Fax number for individual drug forms (forms available for download on website): (855) 840-1678 Fax number for the following states: Arkansas,PHONE: 1-866-503-0857 (TTY: 711) For other lines of business: Please use other form. Note: Beovu is non-preferred. The preferred products are bevacizumab (Avastin) first followed by Byooviz. Avastin (C9257) and bevacizumab biosimilars do not require precertification for ophthalmic use. G. CLINICAL INFORMATION (continued)1-866-752-7021 Injectable Precertification Request FAX: 1-888-267-3277 Page 2 of 4 For Medicare Advantage Part B: (All fields must be completed and legible for precertification review.) Phone: 1-866-503-0857 FAX: 1-844-268-7263 – Patient First Name . Patient Last Name . Patient Phone . Patient DOB . G. CLINICAL INFORMATION (continued)Pulmonary Hypertension (Inhalation or Injectable Medication) Precertification Request. Page 2 of 2. (All fields must be completed and legible for precertification review.) For Medicare Advantage Part B: FAX: 1-844-268-7263. PHONE: 1-866-503-0857. For other lines of business: Please use other form.1-866-752-7021 . Sandostatin, Sandostatin LAR Depot . FAX: 1-888-267-3277 . or Bynfezia Pen . For Medicare Advantage Part B: Phone: 1-866-503-0857 . Medication Precertification Request . FAX: 1-844-268-7263 . Page 3 of 3 (All fields must be completed and legible for precertification review) - Patient First Name . Patient Last Name . Patient ...1-866-503-0857 . For other lines of business: Please use other form. Note: Entyvio is preferred on MA plans. On MAPD plans Entyvio is preferred for ulcerative colitis and non-preferred for Crohn's disease. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date / /

1-866-752-7021 . FAX: 1-888-267-3277 . For Medicare Advantage Part B: Phone: 1-866-503-0857 . FAX: 1-844-268-7263 . Zolgensma (onasemnogene abeparvovec-xioi) Medication Precertification Request. Page 1 of 2 (All fields must be completed and legible for Precertification Review) Please indicate: Start of treatment: Start date. Continuation …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: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:Actually it helps cut down the robo calls because apparently many of the robo callers give up calling as time goes by. — Ronald K, Nov 29th, 11:21am. Block this robocall and over 8,840,584 more with Nomorobo! Stop robocalls with Nomorobo. (866) 602-0857 is a Robocall. Click here to listen.: 1-866-503-0857 . FAX: 1-844-268-7263 . For other lines of business: Please use other form . Note: Darzalex is non-preferred. The preferred products are Bortezomib and Velcade. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date / / Continuation of therapy: Date of last ...1 // // // Soliris (eculizumab) Injectable Medication precertification request Aetna precertification Notification503 Sunport Lane, Orlando, FL 32809 Phone: 1-866-503-0857 FAX: 1-888-267-3277 For Medicare Advantage Part B: FAX: 1-844-268-7263 Page 1 of 3(All fields must be completed and legible for precertification Review.)1-866-752-7021 Medication Precertification Request FAX: 1-888-267-3277 Page 2 of 2 For Medicare Advantage Part B: (All fields must be completed and legible for Precertification Review.) Phone: 1-866-503-0857 FAX: 1-844-268-7263 G. CLINICAL INFORMATION (continued)859-455-8650. CoverMyMeds – Pre-Authorization. 866-503-0857. CoverMyMeds – General Information. 866-452-5017. Aetna Coventry (Workers Compensation and Auto Injury) 800-937-6824. Discover Aetna provider phone numbers. Simplify interactions and access support promptly with accurate and up-to-date contact information.

1-866-503-0857 . FAX: 1-844-268-7263 / / / / Patient First Name Patient Last Name . Patient Phone . Patient DOB . G. CLINICAL INFORMATION (continued) – Required clinical information must be completed in its entirety for all precertification requests.1-866-752-7021 . Sandostatin, Sandostatin LAR Depot . FAX: 1-888-267-3277 . or Bynfezia Pen . For Medicare Advantage Part B: Phone: 1-866-503-0857 . Medication Precertification Request . FAX: 1-844-268-7263 . Page 3 of 3 (All fields must be completed and legible for precertification review) - Patient First Name . Patient Last Name . Patient ...Policy: Precertification Criteria; Under some plans, including plans that use an open or closed formulary, Olysio is subject to precertification.If precertification requirements apply Aetna considers these medications to be medically necessary for those members who meet all of the following precertification criteria.1-866-752-7021 Medication Precertification Request FAX: 1-888-267-3277 Page 2 of 2 For Medicare Advantage Part B: (All fields must be completed and legible for Precertification Review.) Phone: 1-866-503-0857 FAX: 1-844-268-7263 Patient First Name . Patient Last Name . Patient Phone . Patient DOB

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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 .PHONE: 1-866-503-0857 (TTY: 711) For other lines of business: Please use other form. Note: Lupron Depot is non-preferred. The preferred product Page 1 of 3 is Eligard. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date / / Continuation of therapy, Date of last treatment / /( ) Injectable Medication Precertification Request Aetna Precertification Notification 503 Sunport Lane, Orlando, FL 32809 Phone: 1-866-503-0857 FAX: 1-888-267-3277 Page 1 of 2.For Medicare Advantage Part B: FAX: 1-844-268-7263 PHONE: 1-866-503-0857 (TTY: 711) For other lines of business: Please use other form. Note: Lucentis and Cimerli are non- preferred. The preferred products are bevacizumab (Avastin) first followed by Byooviz or Eylea/Eylea HD. Avastin (C9257) and bevacizumab biosimilars do not require ...

1-866-503-0857 (TTY: 711) For other lines of business: Please use other form. Note: Susvimo is non-preferred. The preferred products are bevacizumab (Avastin) first followed by Byooviz or Eylea/Eylea HD. Avastin (C9257) and bevacizumab biosimilars do not require precertification for ophthalmic use. Precertification Requested By:1-866-503-0857 . For other lines of business: Please use other form. Note: Abraxane is non-preferred. The preferred products are docetaxel or paclitaxel. Docetaxel and paclitaxel do not require precertification. (All fields must be completed and legible for Precertification Review.) Please indicate: Start of treatment: Start date / /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: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 …Policy: Precertification Criteria; Under some plans, including plans that use an open or closed formulary, Benlysta is subject to precertification. If precertification requirements apply Aetna considers Benlysta to be medically necessary for those members who meet ALL of the following precertification criteria: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 ...Synagis™ (palivizumab ) Note: Precertification review for these medications is handled through Aetna Specialty Precert Unit at 1-866-503-0857. Refer to Medical CPB #0318 Synagis (Palivizumab) Policy: Precertification Criteria. Under some plans, including plans that use an open or closed formulary, Synagis is subject to precertification.1-866-503-0857. For other lines of business: Please use other form. Note: Granix, Leukine, Neupogen, Nivestym, and Releuko are non-preferred. Zarxio is preferred. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date . Continuation of therapy: Date of last treatmentLucentis® (ranibizumab) Injectable Medication Precertification Request. Page 1 of 2. (All fields must be completed and legible for Precertification Review.) 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: Lucentis is non-preferred.

1-866-752-7021 Medication Precertification Request FAX: 1-888-267-3277 Page 2 of 2 For Medicare Advantage Part B: egible for Precertification Review.) Phone: 1-866-503-0857 FAX: 1-844-268-7263 Patient First Name . Patient Last Name . Patient Phone . Patient DOB . G. CLINICAL INFORMATION (continued)

Medicine Matters Sharing successes, challenges and daily happenings in the Department of Medicine Nadia Hansel, MD, MPH, is the interim director of the Department of Medicine in th...1-866-752-7021 Medication Precertification Request FAX: 1-888-267-3277 Page 2 of 2 For Medicare Advantage Part B: (All fields must be completed and legible for precertification review.) Phone: 1-866-503-0857 FAX: 1-844-268-7263 / / Patient First Name . Patient Last Name . Patient Phone . Patient DOB . G. CLINICAL INFORMATION: 1-866-503-0857 . FAX: 1-844-268-7263 . For other lines of business: Please use other form. Note: Aralast NP, Glassia and Zemaira are non-preferred. The preferred product is Prolastin-C. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date . Continuation of therapy: Date of ...Reverse phone lookup for (866) 503-0857. Find full name, address, email, and photos for owner of (866) 503-0857 with Spokeo.DEKABANK DT.GIROZENTRALESTUFENZINS-ANLEIHE 18(24) (DE000DK0N452) - All master data, key figures and real-time diagram. The DekaBank Deutsche Girozentrale-Bond has a maturity date o...Remicade® (infliximab) Injectable Medication Precertification Request. Page 1 of 5. (All fields must be completed and legible for precertification review.) FAX: 1-844-268-7263. PHONE: 1-866-503-0857. For other lines of business: Please use other form. Note: Remicade is preferred for MA plans. Preferred status for.PHONE: 1-866-503-0857 (TTY: 711) For other lines of business: Please use other form. Note: Beovu is non-preferred. The preferred products are bevacizumab (Avastin) first followed by Byooviz. Avastin (C9257) and bevacizumab biosimilars do not require precertification for ophthalmic use. G. CLINICAL INFORMATION (continued)Lucentis® (ranibizumab) Injectable Medication Precertification Request. Page 1 of 2. (All fields must be completed and legible for Precertification Review.) 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: Lucentis is non-preferred.Remicade® (infliximab) Note: Precertification review for these medications is handled through Aetna Specialty Precert Unit at 1-866-503-0857. Site of Care Utilization Management Policy applies. For information on site of service for Remicade, see Utilization Management Policy on Site of Care for Specialty Drug Infusions at https://www.aetna ...

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Prepare 866 503 0857 effortlessly on any device. Online document management has grown to be popular with businesses and individuals. It provides a perfect eco-friendly replacement for traditional printed and signed documents, as you can get the correct form and securely store it online.1-866-752-7021 . FAX: 1-888-267-3277 . For Medicare Advantage Part B: Phone: 1-866-503-0857 . FAX: 1-844-268-7263 . Zolgensma (onasemnogene abeparvovec-xioi) Medication Precertification Request. Page 1 of 2 (All fields must be completed and legible for Precertification Review) Please indicate: Start of treatment: Start date. Continuation of ...Note: Precertification review for these medications is handled through Aetna Specialty Precert Unit at 1-866-503-0857. Policy: Precertification Criteria; Under some plans, including plans that use an open or closed formulary, Granix, Leukine, Neulasta, Neupogen, and Zarxio are subject to precertification. If precertification requirements apply ...Alirocumab (PraluentTM) Injectable Medication Precertification Request. Aetna Precertification Notification 503 Sunport Lane, Orlando, FL 32809 Phone: 1-866-503-0857. Page 1 of 2. FAX: 1-888-267-3277. (All fields must be completed and legible for precertification review) For Medicare Advantage Part B: FAX: 1-844-268-7263.1-866-752-7021 . Medication Precertification Request . FAX: 1-888-267-3277 Page 2 of 2 . For Medicare Advantage Part B: (All fields must be completed and legible for Precertification Review.) Phone: 1-866-503-0857 FAX: 1-844-268-7263 . Patient First Name . Patient Last Name . Patient Phone . Patient DOB . G. CLINICAL INFORMATION (continued)PHONE: 1-866-503-0857 (TTY: 711) For other lines of business: Please use other form. Note: Eylea and Eylea HD are non-preferred. The preferred product is bevacizumab (Avastin). Avastin (C9257) and bevacizumab biosimilars do not require precertification for ophthalmic use. (All fields must be completed and legible for precertification review.)1-866-752-7021 (TTY: 711) (commercial) or : 1-866-503-0857 (TTY: 711) (Medicare). *Availity is available only to U.S. providers and its territories. The Aetna Premier Care Network Plus program is now multi-tiered : Starting January 1, some of your patients might be in our new Aetna Premier Care Network PlusAetna Precertification Notification 503 Sunport Lane Orlando FL 32809 Phone 1-866-503-0857 FAX 1-888-267-3277 Injectable Medication Precertification Request Please indicate Start of treatment Ship to Doctor s office Patient Continuation of therapy Date needed Phone Dispensing Provider Today s date Other Aetna Specialty Pharmacy or Fax TIN PIN A. DIAGNOSIS INFORMATION Primary ICD-9 170. 0-170 ... ….

Aetna Recertification Notification 503 Support Lane, Orlando, FL 32809 Phone: 1-866-503-0857 FAX: 1-888-267-3277 Viscosupplementation Injectable Medication Recertification Request Please indicate: ... 1-866-503-0857 FAX: 1-888-267-3277 Viscosupplementation Injectable Medication Recertification Request Please indicate: We are not affiliated with ...1-866-503-0857 . For other lines of business: Please use other form. (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 INFORMATION First Name:For precertification of immune globulin human intramuscular injection (IGIM) (GamaSTAN), call (866) 752-7021 (Commercial), or fax (888) 267-3277. For Statement of Medical Necessity (SMN) precertification forms, see Specialty Pharmacy Precertification. For Medicare Part B plans, call (866) 503-0857, or fax (844) 268-7263.Phone: 1-866-503-0857. For other lines of business: Please use other form. Note: Zoladex is non-preferred. The preferred product is Eligard. Firmagon is also a preferred product. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date / / Continuation of therapy, Date of last treatment1-866-752-7021 Medication Precertification Request FAX: 1-888-267-3277 Page 2 of 2 For Medicare Advantage Part B: (All fields must be completed and legible for Precertification Review.) Phone: 1-866-503-0857 FAX: 1-844-268-7263 G. CLINICAL INFORMATION (continued)PHONE: 1-866-503-0857 (TTY: 711) For other lines of business: Please use other form. Note: Beovu is non-preferred. The preferred products are bevacizumab (Avastin) first followed by Byooviz. Avastin (C9257) and bevacizumab biosimilars do not require precertification for ophthalmic use. G. CLINICAL INFORMATION (continued)MEDICARE FORM. Viscosupplementation Injectable Medication Precertification Request. Page 2 of 2. (All fields must be completed and legible for precertification review.) Patient Last Name. Patient Phone. For Medicare Advantage Part B: Phone: 1-866-503-0857 (TTY: 711) FAX: 1-844-268-7263. For other lines of business: Please use other form.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 ...GR-69025-CA (10-14) Page 1New 08/13 of 2 PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM Instructions: Please fill out all applicable sections on both pages completely and legibly . Attach any additional documentation that is1-866-752-7021 Medication Precertification Request FAX: 1-888-267-3277 Page 2 of 2 For Medicare Advantage Part B: (All fields must be completed and legible for precertification review.) Phone: 1-866-503-0857 FAX: 1-844-268-7263 / / Patient First Name . Patient Last Name . Patient Phone . Patient DOB . G. CLINICAL INFORMATION 866-503-0857, 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 Phone . Patient DOB . G. CLINICAL INFORMATION - Required clinical information must be completed in its entirety for all precertification requests., Jun 30, 2023 · June 30, 2023. Many scams start with an intimidating phone call. A “debt collector” needs you to pay immediately. Or a “police officer” claims to have a warrant for your arrest. The latest ..., MEDICARE FORM. Tremfya® (guselkumab) Medication Precertification Request. Page 2 of 2. (All fields must be completed and legible for precertification review.) For Medicare Advantage Part B: FAX: 1-844-268-7263. PHONE: 1-866-503-0857. For other lines of business: Please use other form., 1-866-752-7021 . FAX: 1-888-267-3277 . Page 1 of 1 . 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:, If you've missed credit card payments, even if it's been several months, don't panic. You would probably already know if your credit card company had filed a lawsuit. However, many..., • Call 1-866-503-0857 or fax applicable request forms to 1-888-267-3277<br /> 17. Special programs<br /> Beginning Right ® maternity program<br /> ... • Call 1-866-782-2779 for information on injectable medications not listed<br /> • Visit Clinical Policy Bulletins and DocFind ®<br />, 1-866-503-0857 (All fields must be completed and legible for precertification review) Fax: 1-888-267-3277. For Medicare Advantage Part B: Please Use Medicare Request Form . Patient First Name . Patient Last Name . Patient Phone . Patient DOB . G. CLINICAL INFORMATION (continued), PHONE: 1-866-503-0857 (TTY: 711) For other lines of business: Please use other form. Note: Feraheme, Injectafer, and Monoferric are non-preferred. The preferred products are Ferrlecit (sodium ferric gluconate), Infed, and Venofer. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date, Prepare 866 503 0857 effortlessly on any device. Online document management has grown to be popular with businesses and individuals. It provides a perfect eco-friendly replacement for traditional printed and signed documents, as you can get the correct form and securely store it online., 1-844-268-7263. PHONE: 1-866-503-0857 (TTY: 711) For other lines of business: Please use other form. Note: Vabysmo is non-preferred. The preferred products are bevacizumab (Avastin) first followed by Byooviz or Eylea/Eylea HD. Avastin (C9257) and bevacizumab biosimilars do not require precertification for ophthalmic use., Aetna Specialty Pharmacy phone: 1 (866) 503-0857; All Aetna Forms; By State. California; Colorado; Massachusetts; Michigan; Oregon; Texas (Rx Only) Texas (Services Only) How to Write. Step 1 - Begin by providing the patient's Aetna member number, group number, and specify whether or not the patient is enrolled in Medicare., 1-866-503-0857 . For other lines of business: Please use other form. Note: Renflexis is non-preferred. Preferred products vary based on indication. See section G below. (All fields must be completed and legible for Precertification Review.) Please indicate: Start of treatment: Start date / / Continuation of therapy: Date of last treatment / /, 1-866-752-7021 Medication Precertification Request FAX: 1-888-267-3277 Page 2 of 2 For Medicare Advantage Part B: egible for Precertification Review.) Phone: 1-866-503-0857 FAX: 1-844-268-7263 Patient First Name . Patient Last Name . Patient Phone . Patient DOB . G. CLINICAL INFORMATION (continued), 1-866-503-0857 . For other lines of business: Please use other form. Note: Abraxane is non-preferred. The preferred products are docetaxel or paclitaxel. Docetaxel and paclitaxel do not require precertification. (All fields must be completed and legible for Precertification Review.) Please indicate: Start of treatment: Start date / /, 1-866-752-7021 acetate for depot suspension) FAX: 1-888-267-3277 Medication Precertification Request For Medicare Advantage Part B: Phone: 1-866-503-0857 Page 2 of 2 FAX: 1-844-268-7263 (All fields must be completed and legible for Precertification Review) Patient First Name . Patient Last Name . Patient Phone . Patient DOB . H. …, All you'll need is the 10-digit phone number in question, and you can find out who it belongs to, their location and even what type of phone it is. A reputable service like USPhoneBook.com pulls from billions of records to ensure you get the most up-to-date information available—and put a rest to those mystery numbers once and for all., 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:, 1-866-503-0857 . For other lines of business: Please use other form. Note: Renflexis is non-preferred. Preferred products vary based on indication. See section G below. (All fields must be completed and legible for Precertification Review.) Please indicate: Start of treatment: Start date / / Continuation of therapy: Date of last treatment / /, How to get started. We have several ways for you to fill a prescription through the network specialty pharmacy. New prescriptions: For a new prescription, your doctor can: e-Prescribe NCPDP ID 1466033. Fax your prescription to 1-800-323-2445. Call us at 1-800-237-2767., Phone: 1-866-503-0857 Page 2 of 3 FAX: 1-844-268-7263 (All fields must be completed and legible for Precertification Review.) - Continued on next page G. CLINICAL INFORMATION (continued) - Required clinical information must be completed in its entirety for all precertification requests. GR-68683 (8-19) Patient First Name, in the past 24 hours. Positive. (800) 955-6600. Positive. (877) 255-5923. Negative. (908) 829-0335. Positive. (877) 647-8552. Negative. (303) 209-5564. Positive. (877) 613-7414. …, Exception: Requests for drugs administered by a healthcare professional that will be billed to the medical plan, call 1-866-503-0857 or fax applicable request forms to 1-888-267-3277. For Oral Corticosteroid Clinical policy click here . Policy:, Remicade® (infliximab) Note: Precertification review for these medications is handled through Aetna Specialty Precert Unit at 1-866-503-0857. Site of Care Utilization Management Policy applies. For information on site of service for Remicade, see Utilization Management Policy on Site of Care for Specialty Drug Infusions at https://www.aetna ..., PHONE: 1-866-503-0857 . For other lines of business: Please use other form . Note: Trelstar is non-preferred. The preferred product is Eligard. Firmagon is also a preferred product. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date. Continuation of therapy, Date of last treatment, 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., 1-866-503-0857 . For other lines of business: Please use other form. Note: Xgeva is non-preferred. The preferred products are 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:, 1-866-503-0857 . For other lines of business: Please use other form. Note: Xgeva is non-preferred. The preferred products are 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:, If you are not the intended recipient, you are notified that any use, distribution or copying of the attached material is strictly prohibited and may subject you to criminal or civil penalties. If you received this transmission in error, please notify us immediately by telephone at (866) 503-0857. GR-69377 (5-18), If it is medically necessary for a member to be treated initially with a medication subject to step therapy, the members treating physician may contact the Aetna Pharmacy Management Precertification Unit to request coverage as a medical exception at 1-866-503-0857. (See criteria under section II below). Medical Exception Criteria, 503 Sunport Lane, Orlando, FL 32809. Phone: 1-866-503-0857 . FAX: 1-888-267-3277 . For Medicare Advantage Part B: (All fields must be completed and legible for Precertification Review.) FAX: 1-844-268-7263 Please indicate: Start of treatment: Start date . Continuation of therapy: Date of last treatment . Precertification Requested By: Phone: Fax:, 1-866-503-0857 . For other lines of business: Please use other form. Note: Lupron Depot is non-preferred. The preferred product is Eligard. Firmagon is also a preferred product. Page 1 of 3 (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date / / Continuation of therapy, last ..., 866-503-0857 (Preauthorization) 866-452-5017 (General Information) Aetna Medical and Behavioral health: 888-632-3862: Coventry (Including workers compensation and auto injury) 800-937-6824: Dental: 800-451-7715: Pharmacy: 800-238-6279: Aetna Provider Phone Number for below plans - 800-624-0756;, 1-866-752-7021 Medication Precertification Request FAX: 1-888-267-3277 Page 2 of 2 For Medicare Advantage Part B: (All fields must be completed and legible for Precertification Review.) Phone: 1-866-503-0857 FAX: 1-844-268-7263 G. …