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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)Providers can request prior approval using Transdev's PassPORT system or by phone at 866-503-9040. ... 800-526-0857 Voice Users 800-501-0864 TTY Spanish 800-501-0865 Voice Spanish 877-526-6680 American Standard Code for Information Exchange (ASCII) 877-526-6690 Speech-to-Speech (STS)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 . 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 ...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 dateReverse phone lookup for (866) 503-0857. Find full name, address, email, and photos for owner of (866) 503-0857 with Spokeo.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 ...

Phone: 1-866-752-7021 . Medication Precertification Request . FAX: 1-888-267-3277 . Page 1 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 DOBPhone: 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 INFORMATION First Name: Last Name: Address: City: ...Therefore, the airSlate SignNow web application is a must-have for completing and signing 866 503 0857 on the go. In a matter of seconds, receive an electronic document with a legally-binding eSignature. Get 866 752 7021 signed right from your smartphone using these six tips: Type signnow.com in your phone’s browser and log in to your account. ….

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Note: Precertification review for these medications is handled through Aetna Specialty Precert Unit at 1-866-503-0857. Exception: Member's enrolled in an Individual Plan for the following pharmacy covered drugs - Actemra, Amevive, Cimzia, Cosentyx, Enbrel, Humira, Kineret, Orencia, Otezla, Simponi, Stelara, and Xeljanz please contact Aetna Pharmacy Management Precertification at 1-800-414-23861-866-503-0857 . For other lines of business: Please use other form. Note: Stelara is non-preferred. Preferred products vary based on indication. See section G below. (Please return. Pages 1 to 3. for precertification of medications.) 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: Cimzia 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 treatment1-844-268-7263. 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.

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