ANTIDEPRESSANTS, OTHER PRIOR AUTHORIZATION FORM Please indicate: Start of treatment: Start date. Available for PC, iOS and Android. It's easy to update a provider address, phone number, fax number, email address or initiate an out-of-state move or a change in provider group. 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.) Provider termination form and directory update, Actemra® (Tocilizumab) Precertification Request (PDF), Aranesp® (darbepoetin alfa) Medication Precertification Request (PDF), Avsola™ (infliximab-axxq) Injectable Medication Precertification Request (PDF), Bavencio®(Avelumab) Medication Precertification Request (PDF), Benlysta®(Belimumab) Injectable Medication Precertification Request (PDF), Blenrep (belantamab mafodotin-blmf) Medication Precertification Request (PDF), Botox® (onabotulinumtoxinA) Injectable Medication Precertification Request (PDF), Diabetic Testing Supplies Prior Authorization Request Form (PDF), Dysport® (abobotulinumtoxinA) Injectable Medication Precertification Request (PDF), Entyvio® (Vedolizumab) Injectable Medication Precertification Request (PDF), Epogen® -Procrit® -Retacrit™ (epoetin alfa) Medication Precertification Request (PDF), Epoprostenol, FLOLAN, VELETRI® (epoprostenol) Medication Precertification Request (PDF), Evrysdi™ (risdiplam) Medication Precertification Request (PDF), Eylea® (Aflibercept) Injectable Precertification Request (PDF), Filgrastim Precertification Request (Neupogen®, Granix®, Nivestym®, Zarxio®) (PDF), Firazyr® (icatibant injection) Medication Precertification Request (PDF), GilvaariTM (givosiran) Medication Precertification Request (PDF), Haegarda® (C1 esterase inhibitor, human) Medication Precertification Request (PDF), Herceptin® (trastuzumab) Precertification Request (PDF), H.P Acthar Gel (Repository Corticotropin) Medication Precertification Request (PDF), Hyaluronates (Viscosupplementation) Injectable Medication Precertification Request (PDF), Immune Globulin (IG) Therapy Medication Precertification Request (PDF), Infertility Medication Precertification Request (Female) (PDF), Infertility Medication Precertification Request (Male) (PDF), Inflectra® (Infliximab) Injectable Medication Precertification Request (PDF), Kanjinti™ (trastuzumab-anns) Precertification Request (PDF), Lemtrada® (Alemtuzumab) Medication Precertification Request (PDF), Lucentis® (Ranibizumab) Injectable Medication Precertification Request (PDF), Lupron Depot ® (leuprolide acetate for depot suspension) Medication Precertification Request (PDF), Lupron Depot-PED® (leuprolide acetate for depot suspension) Medication Precertification Request (PDF), Luxturna ® (Voretigene Neparvovec-rzyl) Medication Precertification Request (PDF), Miacalcin® (Calcitonin) Medication Precertification Request (PDF), Mircera® (methoxy polyethylene glycol-epoetin beta) Medication Precertification Request (PDF), Myalept® (Metreleptin) Injectable Medication Precertification Request (PDF), Myobloc® (rimabotulinumtoxinB) Injectable Medication Precertification (PDF), Natpara® (parathyroid hormone) Medication Precertification Request (PDF), Ocrevus™(Ocrelizumab) Medication Precertification Request (PDF), Octreotide acetate injection, Sandostatin®, Sandostatin®, LAR Depot or Bynfezia Pen™ Medication Precertification Request (PDF), Orencia® (Abatacept) Precertification Request (PDF), Pegfilgrastim Precertification Request (Neulasta®, Fulphila®, Udenyca®, Ziextenzo®) (PDF), Prolia® (denosumab) Injectable Medication Precertification Request (PDF), Remicade® (Infliximab) Precertification Request (PDF), Remodulin® (treprostinil) Medication Precertification Request (PDF), Renflexis ® (Infliximab-abda) Injectable Medication Precertification Request (PDF), Rituxan® (Rituximab) Precertification Request (PDF), Ruxience™ (rituximab-pvvr) Medication Precertification Request (PDF), Simponi Aria® (Golimumab) Infusion Medication Precertification Request (PDF), Stelara® (Ustekinumab) Precertification Request (PDF), Truxima™ (rituximab-abbs) Medication Precertification Request (PDF), Tysabri® (Natalizumab) Medication Precertification Request (PDF), Tyvaso® (treprostinil inhalation solution) Medication Precertification Request (PDF), Ventavis® (iloprost inhalation solution) Medication Precertification Request (PDF), Xeomin® (incobotulinumtoxinA) Injectable Medication Precertification Request (PDF), Xgeva® (denosumab) Injectable Medication Precertification Request (PDF), Specialty Medication Precertification Request Form (General) (PDF), California Prescription Drug Prior Authorization (PDF) Spravato® (Esketamine) Page 1 of 9 UnitedHealthcare Oxford Clinical Policy Effective 02/01/2021 ©1996-2021, Oxford Health Plans, LLC . You are now being directed to the US Department of Health and Human Services site, You are now being directed to the CVS Health COVID-19 testing site. Start a free trial now to save yourself time and money! Dental Request Spravato (esketamine) PHYSICIAN INFORMATION PATIENT INFORMATION * Physician Name: *Due to privacy regulations we will not be able to respond via fax with the outcome of our review unless all asterisked (*) items on * DEA, NPI or TIN: this form … 1006 0 obj <> endobj Part D forms: Please see the Medicare section of this page. You are now being directed to the Give an Hour site, You are now being directed to the CVS Pharmacy site, You are now being directed to the CDC site. Please complete all pages to avoid a delay in our decision. SpravatoTM(esketamine) Medication Precertification Request. Holding any member mycare prior authorization before the drug coverage or are available. Assess BP prior to administration of SPRAVATO ®. Continuation of therapy: Date of last treatment. Because of the specialized skills required for evaluation and diagnosis of individuals treated with Spravato as well as the monitoring required for adverse events and efficacy, approval requires Spravato to be prescribed by a physician who specializes in �Ǯi�8Aȭ�6�����_��e�P��Uq�ۮ#o�I�xK/w������=߿K�{U�,*O:��t��� Ohio Electronic Funds Transfer (EFT) Opt Out (PDF) For language services, please call the number on your member ID card and request an operator. UNIFORM PHARMACY PRIOR AUTHORIZATION REQUEST FORM CONTAINS CONFIDENTIAL PATIENT INFORMATION Complete this form in its entirety and send to Rocky Mountain Health Plans at 833-787-9448 Urgent 1 Non-Urgent Requested Drug Name: Spravato® (esketamine) – Good Health Patient Information: Prescribing Provider Information: Patient Name: Prescriber Name: Member/Subscriber … You’ll get a text from us soon with a link to download the Aetna Health app, ABA Requests: Assessment or Service Authorization (PDF), Transcranial Magnetic Stimulation (TMS) (PDF), BH Outpatient Nonpar Provider Request Form (PDF), Medicare Member Authorization Appeal-appealing Medicare denials of medical prior authorization (precertification) requests (PDF), Medicare Appeals Provider Memo- Post Service (PDF), Practitioner and Provider Complaint and Appeal (PDF), Dispute Resolution Request - California (PDF), Electronic Claim Submission Application (PDF), Modafinil and Armodafinil (generic Provigil, Coventry Workers’ Compensation, Coventry Auto Injury, or First Health Request, Prescription Medication Claim (English) (PDF), Prescription Medication Claim (Spanish) (PDF), Filgrastim Precertification Request (Neupogen, Octreotide acetate injection, Sandostatin, Pegfilgrastim Precertification Request (Neulasta, California Prescription Drug Prior Authorization (PDF), Colorado Prescription Drug Prior Authorization (PDF), Connecticut Accident Detail Questionnaire (PDF), Iowa Prescription Drug Prior Authorization (PDF), Louisiana Prescription Drug Prior Authorization (PDF), New Hampshire Prescription Drug Prior Authorization (PDF), New Jersey Appeal a Claim Determination (PDF), New Mexico Uniform Prior Authorization (PDF), New York Contraceptive Exception Request (PDF), Ohio Electronic Funds Transfer (EFT) Opt Out (PDF), Oregon Prescription Drug Prior Authorization (PDF), Texas Prescription Drug Prior Authorization (PDF), Texas Telemedicine and Telehealth Services Reimbursement Policy (PDF), Washington Intent to Use a Substitute Provider (PDF), Washington D.C. Phone: 1-866-752-7021. It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan. Louisiana Prescription Drug Prior Authorization (PDF), Massachusetts Standard Prior Authorization Forms, Michigan Prescription Drug Prior Authorization (PDF), New Hampshire Prescription Drug Prior Authorization (PDF) %%EOF Statement of Understanding (PDF), Autolougous Chondrocyte Implantation (PDF), Breast Reduction and/or Reconstructive Surgery (PDF), Electroencephalographic (EEG) Video Monitoring (PDF), Gender Reassignment Surgery - Aetna Student Health (PDF), Hip Surgery for Impingement Syndrome (PDF), Lower Limb Prosthesis including Microprocessor-Controlled Knee (PDF), Precertification Information Request Form (PDF), Skilled Home Private Duty Nursing Care (PDF), Wheelchairs and Power Operated Vehicles (Scooters) (PDF), Standard Organization Determination Information Request Form, (Note: This is a page on the CMS site that provides information about patient rights as a hospital inpatient. Just enter your mobile number and we’ll text you a link to download the Aetna Health app from the App Store or on Google Play. 1442 0 obj <>stream In patients whose BP is elevated prior to SPRAVATO ® administration (as a general guide: >140/90 mmHg), a decision to delay SPRAVATO ® therapy should take into account the balance of benefit and risk in individual patients. This form asks the medical office for the right to be able to write a prescription to their patient whilst having Aetna cover the cost as stated in the insurance policy (in reference to prescription costs). BP should be monitored for at least 2 hours after SPRAVATO ® administration. Some subtypes have five tiers of coverage. PA requirements and the formulary (list of drugs) subject to PA will vary among insurers. The Aetna prior authorization form is designated for medical offices when a particular patient’s insurance is not listed as eligible. Pharmacy Request Dispute Resolution Request - California (PDF) Electronic Claim Submission Application (PDF) BH Outpatient Nonpar Provider Request Form (PDF). Opioid addiction treatment: For Aetna’s commercial plans, there is no precertification required for buprenorphine products. }U���܈G endstream endobj startxref This form may contain multiple pages. Assess BP prior to administration of SPRAVATO ®. Transcranial Magnetic Stimulation (TMS) (PDF) Texas Prescription Drug Prior Authorization (PDF) Authorized Representative Request (PDF) Medicare Member Authorization Appeal-appealing Medicare denials of medical prior authorization (precertification) requests (PDF) They can also speak with us on your behalf. Fax completed prior authorization request form to 855-247-3677 (Integrated population) or 855-246-7736 (SMI Non-Title population) or submit Electronic Prior Authorization through CoverMyMeds® or SureScripts. Texas Telemedicine and Telehealth Services Reimbursement Policy (PDF) @O�kC���. Health benefits and health insurance plans contain exclusions and limitations. All requested data must be provided. Mail Service Order Form (Spanish) (PDF) Your claim assessment will be delayed if this form is incomplete or contains errors. Delivery of coverage, aetna prior authorization form below to act on your address or services being performed in every loop or log in. Pharmacy Prior Authorization Request Form Do not copy for future use. New Mexico Uniform Prior Authorization (PDF) We'll need to terminate your existing agreement with us. ϐ�)Ãy�B�S1dLf�n���z���Nd�cc!���T��dv�:�%���^QX8Տ���L=���U�a� Ou�l�P>s�! Fill out, securely sign, print or email your AETNA BETTER HEALTH Prior Authorization Form instantly with SignNow. PRIOR AUTHORIZATION REQUEST FORM KETAMINE, SPRAVATO® For authorization, please answer each question and fax this form PLUS chart notes back to the U of U Health Plans Prior Authorization Department. Open and print the PHI form Open and print the PHI form (Spanish) Let someone file a grievance (complaint), ask for coverage or make an appeal for you You can choose someone to do all … If you are writing a prescription of Spravato® Allow at least 24 hours for review. Box 52080 MC 139 Phoenix, AZ 85072-2080 Attn. A standardized, or "uniform," prior authorization (PA) form may be required in … The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. Fax completed prior authorization request form to 877 -309-8077 or submit Electronic Prior Authorization through CoverMyMeds® or SureScripts. Texas Standard Prior Authorization (PDF) Measure blood pressure around 40 … The information you will be accessing is provided by another organization or vendor. Links to various non-Aetna sites are provided for your convenience only. Member has a confirmed diagnosis of severe major depressive disorder (single or recurrent episode), documented by standardized rating scales that reliably measure depressive symptoms (e.g., Beck Depression Scale [BDI], Hamilton Depression Rating Scale [H… Health Details: Aetna Better Health℠ Premier Plan requires prior authorization for select services.However, prior authorization is not required for emergency services. Measure blood pressure around 40 … Precertification Requested By: Spravato™ (esketamine) Medication Precertification Request. �-#��R1$��VB�f��(�ߡa[M�N��n�H�1��n�X�6���ɘ �/�o�����d]����ͷu�5�pz�e�y$c���n�zkU��� h��;NA�mA4D��P�����m�4�t\��# ���S�j��'R�xg�"�6�,���ok��J$�*� ,+i])md� �#ĵ^�O�*����M�L��)ru6�����ÍXe7#��v萫c�ʸ}���~=�86�ukb:5weta;]�w�+�n�ө[���0��l'�s5B�b6��"�& Ϋ�ѱ������p�8�l�Q����{�s�4� Z�î�ɸo�����3�.���rt[Y8�c`�Ci� FM�B9�����x��+�5���%a���ʙsp��܇���|�^}��}�0 �I� Medicare Member Authorization Appeal-appealing Medicare denials of medical prior authorization (precertification) requests (PDF) This form must be completed by the prescribing provider. Aetna Precertification Notification. 0 Prior Authorization Forms - Aetna Better Health. FAX: 1-888-267-3277. Member Complaint and Appeal (PDF) Iowa Prescription Drug Prior Authorization (PDF) For your convenience, there are 3 ways to complete a Prior Authorization request: Applications and forms for healthcare professionals and their patients. Continue In completing and submitting this form for prior-authorization, I attest that I am registered in the Spravato Risk Evaluation and Mitigating Strategy (REMS) program, and legally authorized to prescribe and administer Spravato. UnitedHealthcare® Oxford Clinical Policy Spravato® (Esketamine) Policy Number: PHARMACY 318.8 T2 Effective Date: February 1, 2021 Instructions for Use . Prior authorization (PA) is a routine process used by insurers to confirm that certain drugs or services are used correctly and only when medically necessary. The page includes detailed information and links to CMS forms. Uniform Consultation Referral. 1234 0 obj <>/Encrypt 1007 0 R/Filter/FlateDecode/ID[<281A23C54F1C8FD2419FC00DDD6C9224><65C687CDE894E44BA145A551F4ECAB41>]/Index[1006 437]/Info 1005 0 R/Length 355/Prev 927627/Root 1008 0 R/Size 1443/Type/XRef/W[1 3 1]>>stream Clinical Services Fax: 1-877-378-4727 Message: Attached is a Prior Authorization request form. Thanks! New Jersey Appeal a Claim Determination (PDF) Two separate forms are used to request prior authorization, depending if you are prescribing and administering Spravato®, or if you are prescribing, dispensing, and administering Spravato®. Do you want to continue? For other language services: Español | 中文 | Tiếng Việt |한국어 |Tagalog | Pусский | العربية | Kreyòl | Français | Polski | Português | Italiano |Deutsch |日本語 |فارسی | Other languages ... You are now being directed to the AMA site. Prior Authorization is recommended for prescription benefit coverage of Spravato. This form will also update your information on the online provider directory. NPI Exemption Notification, Medical or Behavioral Health Request SPRAVATO ® (esketamine) Nasal ... A standardized, or "uniform," prior authorization (PA) form may be required in certain states to submit PA requests to a health plan for review, along with the necessary clinical documentation. GR-69472 (6-20) Page 1 of 2 /. Aetna Better Health℠ Premier Plan requires prior authorization for select services. Electronic prior authorization (ePA) At Aetna Better Health ® of Illinois, we make sure that you have all the right tools and technology to help our members. Coventry Workers’ Compensation, Coventry Auto Injury, or First Health Request, Oral Surgery Precertification Request (PDF), Orthognathic Surgery Precertification Request (PDF), Sleep Apnea Appliance Precertification Information Request (PDF), TMJ Treatment Precertification Information Request (PDF), Infertility Program Patient Registration (PDF), Mail Service Order Form (English) (PDF) Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. All requested data must be provided. Incomplete forms or forms … Uniform Consultation Referral (Appendix 43-1). If you are not REMS certified, you are not allowed to … You are now being directed to the CVS Health site. For Medicare Advantage Part B: … Washington Intent to Use a Substitute Provider (PDF) Each main plan type has more than one subtype. If your're retiring, moving out of state or changing provider groups, use this form to notify us. To request a prior authorization, be sure to: Always verify member eligibility prior to providing services; Complete the appropriate authorization form (medical or prescription) Note: REQUIRES PRECERTIFICATIONFootnotes* Aetna considers esketamine (Spravato) nasal spray medically necessary for the treatment of treatment-resistant depression (TRD) in adults (18 years of age or older) when the following criteria are met: 1. medication, and who will be administering Spravato® and monitoring the patient, needs to complete, sign, and submit a prior-authorization form. If you do not intend to leave our site, close this message. When you request prior authorization for a member, we’ll review it and get back to you according to the following timeframes: Routine – 10 calendar days upon receipt of request. If you have questions, please call 800-310-6826. A physician will need to fill in the form with the patient’s medical information and submit it to CVS/Caremark for assessment. You are now leaving Aetna Better Health of California. Colorado Prescription Drug Prior Authorization (PDF) Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). For more information, please contact a Provider Relations representative at 1‑866‑600-2139 for more information. Drug Prior Authorization Form Spravato (Esketamine) The purpose of this form is to obtain information required to assess your drug claim. Medicare Appeals Provider Memo- Post Service (PDF) Facility Request However, prior authorization is not required for emergency services. Washington D.C. Fax completed prior authorization request form to 855-247-3677 (Integrated population) or 855-246-7736 (SMI Non- Title population) or submit Electronic Prior Authorization through CoverMyMeds® or SureScripts. If so, you’ll need to mail us an Authorization for Release of Protected Health Information (PHI) form. Continued on next page. Aetna Authorization Form. Incomplete forms or forms without the chart notes will be returned %PDF-1.6 %���� You are now being directed to the Apple.com COVID-19 Screening Tool. All requested data must be provided. Authorized Representative Request (PDF) BP should be monitored for at least 2 hours after SPRAVATO ® administration. ABA Requests: Assessment or Service Authorization (PDF) Aetna is proud to be part of the CVS Health family. �"�ݾim����,�B� ��b��,t�WҠn��f�Q�����xL�'T IMPORTANT: Please answer all questions. That’s why we’ve partnered with CoverMyMeds ® and Surescripts to provide you with a new way to request a pharmacy prior authorization … This form must be completed by the prescribing provider. If the form is missing information, the PA will not be processed. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy or privacy practices of linked sites, or for products or services described on these sites. REQUIRED: Office notes, labs and medical testing relevant to request showing medical justification to support diagnosis . Fax completed prior authorization request form to 877 -309-8077 or submit Electronic Prior Authorization through CoverMyMeds® or SureScripts. For Medical Pharmacy please fax requests to 801-213-1547. Others have four tiers, three tiers or two tiers. For Retail … Connecticut Accident Detail Questionnaire (PDF) These standard forms can be used across payers and health benefit managers. Fax completed prior authorization request form to 800-854-7614 or submit Electronic Prior Authorization through CoverMyMeds® or SureScripts. Failure to submit clinical documentation to support this request will result in delay and/or denial of the request. Spravato - Virginia Prior Authorization Request Form Please complete this entire form and fax it to: 866-940-7328. For Part D prior authorization forms, please see the Medicare section. Prescription Medication Claim (Spanish) (PDF). Learn all about the prior authorization process. New York Contraceptive Exception Request (PDF) Prescription Medication Claim (English) (PDF) Practitioner and Provider Complaint and Appeal (PDF), Dispute Resolution Request (PDF) If your're moving or changing jobs, you can sign a new agreement for your new practice or location. ), Part D prescription drug prior authorizations and exceptions, General prescription drug coverage determination (PDF), General prescription drug coverage determination (through SilverScript), Lidocaine Products (generic Lidoderm®) (PDF), Modafinil and Armodafinil (generic Provigil®) (PDF), Oral ondansetron (oral generic Zofran®) (PDF), Zolpidem tartrate (generic Ambien® immediate release) (PDF), Tier exception (cost share reduction) request (PDF), CMS General Coverage Determination Request Form (PDF), Abraxane® (albumin-bound paclitaxel) Medicare (PDF), ADAKVEO® (crizanlizumab) Medication Precertification Request (PDF), Adcetris® (Brentuximab Vedotin) Injectable Medication Precertification Request (PDF), 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