Clinical Services Fax: 1-877-378-4727 Message: Attached is a Prior Authorization request form. Opioid addiction treatment: For Aetna’s commercial plans, there is no precertification required for buprenorphine products. Uniform Consultation Referral (Appendix 43-1). Phone: 1-866-752-7021. @O�kC���. For Medicare Advantage Part B: … 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. For language services, please call the number on your member ID card and request an operator. That’s why we’ve partnered with CoverMyMeds ® and Surescripts to provide you with a new way to request a pharmacy prior authorization … Texas Standard Prior Authorization (PDF) SpravatoTM(esketamine) Medication Precertification Request. Prescription Medication Claim (Spanish) (PDF). This form may contain multiple pages. You are now being directed to the CVS Health site. BP should be monitored for at least 2 hours after SPRAVATO ® administration. Transcranial Magnetic Stimulation (TMS) (PDF) ABA Requests: Assessment or Service Authorization (PDF) BP should be monitored for at least 2 hours after SPRAVATO ® administration. Incomplete forms or forms … You are now leaving Aetna Better Health of California. Please complete all pages to avoid a delay in our decision. Applications and forms for healthcare professionals and their patients. Links to various non-Aetna sites are provided for your convenience only. IMPORTANT: Please answer all questions. endstream endobj startxref Fax completed prior authorization request form to 800-854-7614 or submit Electronic Prior Authorization through CoverMyMeds® or SureScripts. Oregon Prescription Drug Prior Authorization (PDF) Prescription Medication Claim (English) (PDF) Texas Telemedicine and Telehealth Services Reimbursement Policy (PDF) %PDF-1.6 %���� }U���܈G You are now being directed to the Apple.com COVID-19 Screening Tool. 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. Measure blood pressure around 40 … 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. Delivery of coverage, aetna prior authorization form below to act on your address or services being performed in every loop or log in. C�yv�r-"�p�e���Iߠ���F�8�~����,_"!��Fs�H��ᓬ��J;�J�L���a�>�{of_ �oi����jz���/�C&���->]���:�������"[��2X���+M���C|(��9�]���l��f"��| 2���|�̊�@c1�44o�9Q����'+Qؼ~���T2&�O�P5nLS�$R%ːq@�U�T�=�v��k�����U�D�����ڽ. 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. 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 … Learn all about the prior authorization process. Texas Prescription Drug Prior Authorization (PDF) 1442 0 obj <>stream Please log in to your secure account to get what you need. Colorado Prescription Drug Prior Authorization (PDF) Medicare Appeals Provider Memo- Post Service (PDF) Holding any member mycare prior authorization before the drug coverage or are available. PA requirements and the formulary (list of drugs) subject to PA will vary among insurers. Continuation of therapy: Date of last treatment. This search will use the five-tier subtype. Authorized Representative Request (PDF) Medicare Member Authorization Appeal-appealing Medicare denials of medical prior authorization (precertification) requests (PDF) FAX: 1-888-267-3277. Fax completed prior authorization request form to 877 -309-8077 or submit Electronic Prior Authorization through CoverMyMeds® or SureScripts. �Ǯi�8Aȭ�6�����_��e�P��Uq�ۮ#o�I�xK/w������=߿K�{U�,*O:��t��� Pharmacy Prior Authorization Request Form Do not copy for future use. If you have questions, please call 800-310-6826. Prior Authorization is recommended for prescription benefit coverage of Spravato. We'll need to terminate your existing agreement with us. Connecticut Accident Detail Questionnaire (PDF) Washington D.C. Facility Request 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 Health benefits and health insurance plans contain exclusions and limitations. Louisiana Prescription Drug Prior Authorization (PDF), Massachusetts Standard Prior Authorization Forms, Michigan Prescription Drug Prior Authorization (PDF), New Hampshire Prescription Drug Prior Authorization (PDF) Each main plan type has more than one subtype. If the form is missing information, the PA will not be processed. Available for PC, iOS and Android. Ohio Electronic Funds Transfer (EFT) Opt Out (PDF) New Mexico Uniform Prior Authorization (PDF) 1006 0 obj <> endobj ϐ�)Ãy�B�S1dLf�n���z���Nd�cc!���T��dv�:�%���^QX8Տ���L=���U�a� Ou�l�P>s�! 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. 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 … Some subtypes have five tiers of coverage. A standardized, or "uniform," prior authorization (PA) form may be required in … 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. Prior Authorization Forms - Aetna Better Health. Aetna is proud to be part of the CVS Health family. Iowa Prescription Drug Prior Authorization (PDF) Please indicate: Start of treatment: Start date. Practitioner and Provider Complaint and Appeal (PDF), Dispute Resolution Request (PDF) Spravato - Virginia Prior Authorization Request Form Please complete this entire form and fax it to: 866-940-7328. This form must be completed by the prescribing provider. This form must be completed by the prescribing provider. 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®. Assess BP prior to administration of SPRAVATO ®. For Part D prior authorization forms, please see the Medicare section. 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. It lets this person access your personal health information. However, prior authorization is not required for emergency services. A physician will need to fill in the form with the patient’s medical information and submit it to CVS/Caremark for assessment. 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. All requested data must be provided. Member Complaint and Appeal (PDF) Allow at least 24 hours for review. They can also speak with us on your behalf. Links to various non-Aetna sites are provided for your convenience only. medication, and who will be administering Spravato® and monitoring the patient, needs to complete, sign, and submit a prior-authorization form. 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� If you are writing a prescription of Spravato® 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. New York Contraceptive Exception Request (PDF) 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). All requested data must be provided. 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. 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 For Part D prior authorization forms, please see the Medicare section. If you are not REMS certified, you are not allowed to … The page includes detailed information and links to CMS forms. ), 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), Aldurazyme® (laronidase) Medication Precertification Request (PDF), Alpha 1 Antitrypsin Inhibitor Therapy Precertification Request (PDF), Avsola (infliximab-axxq) 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