Pharmacy 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 … 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 … Fax completed prior authorization request form to 800-854-7614 or submit Electronic Prior Authorization through CoverMyMeds® or SureScripts. These standard forms can be used across payers and health benefit managers. Texas Prescription Drug Prior Authorization (PDF) 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. Precertification Requested By: You are now leaving Aetna Better Health of California. Your claim assessment will be delayed if this form is incomplete or contains errors. 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 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. Authorized Representative Request (PDF) Medicare Member Authorization Appeal-appealing Medicare denials of medical prior authorization (precertification) requests (PDF) Measure blood pressure around 40 … For more information, please contact a Provider Relations representative at 1‑866‑600-2139 for more information. Fax completed prior authorization request form to 877 -309-8077 or submit Electronic Prior Authorization through CoverMyMeds® or SureScripts. 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. SpravatoTM(esketamine) Medication Precertification Request. 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. Spravato - Virginia Prior Authorization Request Form Please complete this entire form and fax it to: 866-940-7328. If you are not REMS certified, you are not allowed to … Dispute Resolution Request - California (PDF) 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. Holding any member mycare prior authorization before the drug coverage or are available. ANTIDEPRESSANTS, OTHER PRIOR AUTHORIZATION FORM Box 52080 MC 139 Phoenix, AZ 85072-2080 Attn. Some subtypes have five tiers of coverage. Continued on next page. Available for PC, iOS and Android. Links to various non-Aetna sites are provided for your convenience only. New Mexico Uniform Prior Authorization (PDF) The information you will be accessing is provided by another organization or vendor. Continuation of therapy: Date of last treatment. 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. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. BP should be monitored for at least 2 hours after SPRAVATO ® administration. 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 … Texas Standard Prior Authorization (PDF) New York Contraceptive Exception Request (PDF) The page includes detailed information and links to CMS forms. Medicare Appeals Provider Memo- Post Service (PDF) endstream endobj startxref 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. However, prior authorization is not required for emergency services. Dental Request Louisiana Prescription Drug Prior Authorization (PDF), Massachusetts Standard Prior Authorization Forms, Michigan Prescription Drug Prior Authorization (PDF), New Hampshire Prescription Drug Prior Authorization (PDF) If you are writing a prescription of Spravato® 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). Thanks! Clinical Services Fax: 1-877-378-4727 Message: Attached is a Prior Authorization request form. Part D forms: Please see the Medicare section of this page. Incomplete forms or forms without the chart notes will be returned Pharmacy Prior Authorization Request Form Do not copy for future use. You are now being directed to the CVS Health site. Spravato™ (esketamine) Medication Precertification Request. Authorized Representative Request (PDF) 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. 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). PA requirements and the formulary (list of drugs) subject to PA will vary among insurers. This form must be completed by the prescribing provider. Health Details: Aetna Better Health℠ Premier Plan requires prior authorization for select services.However, prior authorization is not required for emergency services. Drug Prior Authorization Form Spravato (Esketamine) The purpose of this form is to obtain information required to assess your drug claim. 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®. Member Complaint and Appeal (PDF) We'll need to terminate your existing agreement with us. Medicare Member Authorization Appeal-appealing Medicare denials of medical prior authorization (precertification) requests (PDF) 0 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. UnitedHealthcare® Oxford Clinical Policy Spravato® (Esketamine) Policy Number: PHARMACY 318.8 T2 Effective Date: February 1, 2021 Instructions for Use . ABA Requests: Assessment or Service Authorization (PDF) 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. Uniform Consultation Referral. Assess BP prior to administration of SPRAVATO ®. For Medicare Advantage Part B: … If so, you’ll need to mail us an Authorization for Release of Protected Health Information (PHI) form. The Aetna prior authorization form is designated for medical offices when a particular patient’s insurance is not listed as eligible. All requested data must be provided. Others have four tiers, three tiers or two tiers. 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. Please indicate: Start of treatment: Start date. Delivery of coverage, aetna prior authorization form below to act on your address or services being performed in every loop or log in. This form may contain multiple pages. Electronic Claim Submission Application (PDF) To request a prior authorization, be sure to: Always verify member eligibility prior to providing services; Complete the appropriate authorization form (medical or prescription) %%EOF Proprietary Form effective 1/1/20 ANTIDEPRESSANTS, OTHER PRIOR AUTHORIZATION FORM Prior authorization guidelines for Antidepressants, Other are available on the DHS Pharmacy Services website at 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) Measure blood pressure around 40 … ), 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) Precertification Request (PDF), Avastin™ (bevacizumab) Mvasi™ (bevacizumab-awwb) Zirabev™ (bevacizumab-bvzr) Medication Precertification Request (PDF), Aveed Medication Precertification Request (PDF), Bavencio® (Avelumab) Medication Precertification Request (PDF), Bendamustine (Treanda®, Bendeka®, Belrapzo™) Medication Precertification Request (PDF), Benlysta® (Belimumab) Injectable Medication Precertification Request (PDF), Beovu® (brolucizumab-dbll) Injectable Medication Precertification Request (PDF), Berinert® (C1 esterase inhibitor, human) Medication Precertification Request (PDF), Besponsa®(Inotuzumab Ozogamicin) Medication Precertification Request (PDF), Brineura® (cerliponase alfa) Medication Precertification Request (PDF), Cerezyme® (imiglucerase) Medication Precertification Request (PDF), Cimzia® (Certolizumab) Precertification Request (PDF), Cinqair® (Reslizumab) Medication Precertification Request (PDF), Cinryze® (C1 esterase inhibitor, human) Medication Precertification Request (PDF), Crysvita® (burosumab-twza) Injectable Medication Precertification Request (PDF), Cyramza® (Ramucirumab) Medication Precertification Request (PDF), Darzalex™ (Daratumumab) Medication Precertification Request (PDF), Darzalex Faspro™ (daratumumab and hyaluronidase-fihj) Medication Precertification Request (PDF), Elaprase® (idursulfase) Medication Precertification Request (PDF), Elelyso® (taliglucerase alfa) Medication Precertification Request (PDF), Eligard® (leuprolide acetate suspension) Medication Precertification Request (PDF), Emend® (Fosaprepitant) Injectable Medication Precertification Request (PDF), Empliciti™ (Elotuzumab) Medication Precertification Request (PDF), Enhertu® (fam-trastuzumab deruxtecan-nxki) Medication Precertification Request (PDF), Erbitux® (Cetuximab) Injectable medication precertification Request (PDF), Erythropoiesis Stimulating Agents (ESAs) Medications Medicare (PDF), Exondys51® (Eteplirsen) Injectable Precertification Request (PDF), Fabrazyme® (agalsidase beta) Medication Precertification Request (PDF), Fasenra™ (Benralizumab) Injectable Medication Precertification Request (PDF), Feraheme® (ferumoxytol) and Injectafer® (ferric carboxymaltose) Medication Precertification Request (PDF), Firmagon® (degarelix) Medication Precertification Request (PDF), Fulphila™ (pegfilgrastim-jmdb) Medicare (PDF), Gattex® (Teduglutide) Injectable Medication Precertification Request (PDF), Gazyva® (Obinutuzumab) Injectable Medication Precertification Request (PDF), Gilenya® (Fingolimod) Medication Precertification Request (PDF), Gilvaari™ (givosiran) Medication Precertification Request (PDF), Herceptin ® (Trastuzumab) Precertification Request (PDF), Herzuma™ (trastuzumab-pkrb) Medication Precertification Request (PDF), Herceptin Hylecta™ (trastuzumab and hyaluronidase-oysk) Precertification Request (PDF), Ilaris® (Canakinumab) Injectable Medication Precertification Request (PDF), Imfinzi® (Durvalumab) Injectable Medication Precertification Request (PDF), Imlygic™ (Talimogene Laherparepvec) Medication Precertification Request (PDF), Immune Globulin (IG) Therapy Medicare (PDF), Jelmyto™ (mitomycin) Medication Precertification Request (PDF), Kadcyla® (ado-trastuzumab) Precertification Request (PDF), Kalbitor® (ecallantide) Medication Precertification Request (PDF), Kanjinti (trastuzumab-anns) Precertification Request (PDF), Kanuma® (sebelipase alfa) Medication Precertification Request (PDF), Keytruda®(Pembrolizumab) Injectable Medication Precertification Request (PDF), Lartruvo™ (Olaratumab) Medication Precertification Request (PDF), Leukine® (sargramostim) Medication Precertification Request (PDF), Levoleucovorin (Fusilev®, Khapzory™) Injectable Medication Precertification Request (PDF), Libtayo® (cemiplimab) Medication Precertification Request (PDF), Lumizyme® (alglucosidase alfa) Medication Precertification Request (PDF), Lumoxiti™ (moxetumomab pasudotox)) Medication Precertification Request (PDF), Lupron Depot® (leuprolide acetate for depot suspension) Medication Precertification Request (PDF), Luxturna® (Voretigene Neparvovec-rzyl) Medication Precertification Request (PDF), Macugen® (Pegaptanib Sodium) Injectable Medication Precertification Request (PDF), Makena® 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Precertification Request (PDF), Phesgo™ (pertuzumab, trastuzumab, and hyaluronidase-zzxf) Medication Precertification Request (PDF), Prolia®, Xgeva® (Denosumab) Medicare (PDF), Provenge Medication Precertification Request (PDF), Radicava™ (Edaravone) Medication Precertification Request (PDF), Reblozyl® (luspatercept-aamt) Medication Precertification Request (PDF), Pulmonary Arterial Hypertension (Infusible, Inhalation, or Injectable Medication) Medicare (PDF), Renflexis® (Infliximab-abda) Medicare (PDF), Rituxan Hycela® (rituximab and hyaluronidase) Medication Precertification Request (PDF), Ruconest® (C1 esterase inhibitor, recombinant) Medication Precertification Request (PDF), Ruxience (rituximab-pvvr) Precertification Request (PDF), Sandostatin® LAR (octreotide acetate) Medication Precertification Request (PDF), Sarclisa® (isatuximab-irfc) Medication Precertification Request (PDF), Signifor® (pasireotide) Medication Precertification Request (PDF), Signifor® LAR (pasireotide) Medication Precertification Request (PDF), Simponi Aria (golimumab) Precertification Request (PDF), Soliris® (Eculizumab) Medication Precertification Request (PDF), Somatuline Depot® (lanreotide) Medication Precertification Request (PDF), Somavert® (pegvisomant) Medication Precertification Request (PDF), Spinzara® (Nusinersen) Injectable Precertification Request (PDF), Spravato™ (esketamine) Medication Precertification Request (PDF), Strensiq® (asfotase alfa) Injectable Medication Precertification Request (PDF), Synagis® (Palivizumab) Injectable Medication Precertification Request (PDF), Takhzyro® (C1 esterase inhibitor, recombinant) Medication Precertification Request (PDF), Tecentriq™ (Atezolizumab) Medication Precertification Request (PDF), Tegsedi™ (inotersen) Medication Precertification Request (PDF), Tepezza™ (teprotumumab-trbw) Medication Precertification Request (PDF), Trazimera® (trastuzumab-qyyp) Precertification Request (PDF), Trelstar® (triptorelin pamoate) Medication Precertification Request (PDF), Tremfya® (Guselkumab) Medication Precertification Request (PDF), Trodelvy™ (sacituzumab govitecan-hziy) Medication Precertification Request (PDF), Truxima (rituximab-abbs) Precertification Request (PDF), Udenyca™ (pegfilgrastim-cbqv) Precertification Request (PDF), Ultomiris™ (ravulizumab-cwvz) Precertification Request (PDF), Uplizna™ (inebilizumab-cdon) Medication Precertification Request (PDF), Vectibix® (Panitumumab) Injectable medication precertification Request (PDF), Viltepso™ (viltolarsen) Medication Precertification Request (PDF), Vimizim® (elosulfase alfa) Medication Precertification Request (PDF), Viscosupplementation Medications Medicare (PDF), VPRIV® (velaglucerase alfa) Medication Precertification Request (PDF), Vyepti™ (eptinezumab-jjmr) Medication Precertification Request (PDF), Vyondys 53® (golodirsen) Injectable Medication Precertification Request (PDF), Xofigo® (Radium-223 dichloride) Injectable Medication Precertification Request (PDF), Xolair®(Omalizumab) Medication Precertification (PDF), Yervoy® (Ipilimumab) Injectable Medication Precertification Request (PDF), Zarxio® (filgrastim-sndz) Medication Precertification Request (PDF), Ziextenzo (pegfilgrastim-bmez) Precertification Request (PDF), Zoladex® (goserelin acetate) Medication Precertification Request (PDF), Zolgensma Medication Precertification Request (PDF), Zulresso™ (brexanolone) Medication Precertification Request (PDF), NPI Submission
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