You can report suspected fraud or any other non-compliance activity by calling our Member Services Department at 877-336-2069 or TTY at 877-206-0500. While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy, medical necessity determinations in connection with coverage decisions are made on a case by case basis. Clinical Prior Authorizations Implemented. Requests will only be treated as urgent for clinical reasons. Join the First Health Network request, Authorized Representative request (PDF) . Selecting the first letter of the drug from the A to Z list up top. How to Write. Step therapy is a type of prior authorization for drugs that require patients to initiate treatment for a medical condition with the most preferred drug therapy. Health (6 days ago) Forms & Documents - Your South Florida Medicare Provider. If you do not intend to leave our site, please click Close. For assistance in registering for or accessing the secure provider website, please contact your provider relations representative at 1-855-676-5772 (TTY 711 ). Your benefits plan determines coverage. 2022 Please confirm the member's plan and group before choosing from the list below. Note: This form will also update your information on our online provider directory. Complete this form to request a formulary exception, tiering exception, prior authorization or reimbursement. Go to the American Medical Association Web site. In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. Case management referral form. The Centers for Medicare & Medicaid Services (CMS) now allows Medicare Advantage (MA) plans to apply step therapy for physician-administered and other Part B drugs. Step 1 - Begin by downloading the form in Adobe PDF and opening it up in the PDF reader of your choice. By filling and submitting this form, the medical professional may be able to secure coverage of a particular prescription for their patient. Meridian Prior authorizations should be submitted through thenew provider portalor via fax. Member Services Toll Free. Peer-to-peer consultations occur between the treating practitioner and an Aetna Better Health medical director. For questions, call (866) 796-0530, ext. OptumRX Prior Prescription Authorization Form. For prior authorization requests for drugs or drug classes not listed below, please fax in your request to 1 . Many drug benefits associated with Quartzs High Deductible Health Plans (HDHPs) require prior authorization for non-preferred medications. Start today by creating a free account, or logging in to your existing account at covermymeds.com. Step 1 - At the top of the page, enter the plan/medical group name, the plan/medical group phone number, and the plan/medical group fax number. Go Claims Payments Coronavirus disease 2019 (COVID-19) Coding Guidelines Compliance Program Requirements Medical/Vision Claim Form. Las Vegas, NV 89114-5645. This is accomplished by providing information and education about available resources to support the member and family toward recovery, including available clinical services and supports for housing, food, medication, and other social problems, Crisis stabilization unit after 144 units, Substance use disorder residential programs after three days, PRTF/acute inpatient mental health treatment, Peer recovery support services after 90 units per month, For assistance with issues of practice management/billing/claims, feel free to contact your designated, Home Delivery/Prescription Reimbursements, Publicly Available Application Programming Interfaces, Patient Access APIs (To Access Your Data Through a 3rd Party App). Medicare Contracted Practitioner/Provider Complaint and Appeal request (PDF) Hep-C Prior Authorization form. Blood Modifiers (Cosela, Fulphila, Granix, Neupogen, Nivestym, Releuko, Ziextenzo) Open a PDF. Actemra (tocilizumab) IV Medication Precertification request (PDF), Aduhelm (aducanumab-avwa) Medication Precertification request (PDF), Adakveo (crizanlizumab) Medication Precertification request (PDF), Adcetris (brentuximab vedotin) Injectable Medication Precertification request (PDF), Aldurazyme (Iaronidase) Medication Precertification request (PDF), Alpha 1 Proteinase Inhibitors Medication Precertification request (PDF), AMONDYS 45 (casimersen) Injectable Medication Precertification Request (PDF), Amvuttra (vutrisiran) Injectable Medication Precertification Request (PDF), Aranesp (darbepoetin alfa) Medication Precertification request (PDF), Avastin (bevacizumab), Mvasi (bevacizumab-awwb), Zirabev (bevacizumab-bvzr) Medication Precertification request (PDF), Aveed (testosterone undecanoate injection) Medication Precertification Request (PDF), Bavencio (avelumab) Injectable 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), Blenrep (belantamab mafodotin-blmf) Medication Precertification request (PDF), Brineura (cerliponase alfa) Medication Precertification request (PDF), bortezomib-Velcade Medication Precertification Request (PDF), Botox (onabotulinumtoxinA) Injectable Medication Precertification request (PDF), Cerezyme (imiglucerase) Medication Precertification request (PDF), Cimzia (certolizumab) Injectable Medication Precertification request (PDF), Cinqair (reslizumab) Medication Precertification request (PDF), Cinryze (C1 esterase inhibitor, human) Medication Precertification request (PDF), Cosela (trilaciclib) Medication Precertification request (PDF), Crysvita (burosumab-twza) Injectable Medication Precertification request (PDF), Cyramza (ramucirumab) Medication Precertification request (PDF), DANYELZA (naxitamab-gqgk) Medication Precertification request (PDF), Darzalex (daratumumab) Medication Precertification request (PDF), Darzalex Faspro (daratumumab and hyaluronidase-fihj) Medication Precertification request (PDF), Diabetic Testing Supplies Prior Authorization request Form (PDF), Dysport (abobotulinumtoxinA) Injectable 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), Empliciti (elotuzumab) Medication Precertification request (PDF), Enhertu (fam-trastuzumab deruxtecan-nxki) Medication Precertification request (PDF), Enjaymo (sutimlimab-jome) Medication Precertification request (PDF), Epogen-Procrit-Retacrit (epoetin alfa) Medication Precertification request (PDF), Epoprostenol, Flolan, Veletri (epoprostenol) Medication Precertification request (PDF), Evkeeza (evinacumab-dgnb) Medication Precertification request (PDF), Evrysdi (risdiplam) Medication Precertification request (PDF), Exondys51 (eteplirsen) Injectable Precertification request (PDF), Eylea (aflibercept) 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), Filgrastim (Neupogen, Granix, Nivestym, Zarxio) Medication Precertification request (PDF), Firazyr - Sajazir (icatibant injection) Medication Precertification request (PDF), Firmagon (degarelix) Medication Precertification request (PDF), FYARRO (sirolimus protein-bound particles for injectable suspension) (albumin-bound) Medication Precertification Request (PDF), Gattex (teduglutide) Injectable Medication Precertification request (PDF), Gilvaari (givosiran) Medication Precertification request (PDF), Haegarda (C1 esterase inhibitor, human) Medication Precertification request (PDF), Herceptin and Trastuzumab Biosimilars Precertification request (PDF), Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Precertification request (PDF), Acthar Gel (repository corticotropin), Purified Cortrophin Gel (repository corticotropin) Injectable Medication Precertification Request (PDF), Hyaluronates (viscosupplementation) Injectable Medication Precertification request (PDF), Imfinzi (durvalumab) Injectable Medication Precertification request (PDF), Imlygic (talimogene laherparepvec) Medication Precertification request (PDF), Immune Globulin (IG) Therapy Medication and/or Infusion Precertification request (PDF), Infertility (Female) Injectable Medication Precertification request (PDF), Infertility (Male) Injectable Medication Precertification request (PDF), Inflectra (infliximab-dyybb) Injectable Medication Precertification request (PDF), Jelmyto (mitomycin) Medication Precertification request (PDF), Kadcyla (ado-trastuzumab) Precertification request (PDF), Kalbitor (ecallantide) Medication Precertification request (PDF), Kanuma (sebelipase alfa) Medication Precertification request (PDF), Keytruda (pembrolizumab) Injectable Medication Precertification request (PDF), KIMMTRAK (tebentafusp-tebn) Injectable Medication Precertification request (PDF), Kyprolis (carfilzomib) Medication Precertification Request (PDF), Lartruvo (olaratumab) Medication Precertification request (PDF), Lemtrada (alemtuzumab) Medication Precertification request (PDF), Leqvio (inclisiran) Medication Precertification request (PDF), Leukine (sargramostim) Medication Precertification request (PDF), Levoleucovorin (Fusilev, Khapzory) Injectable Medication Precertification request (PDF), Libtayo (cemiplimab) Medication Precertification request (PDF), Lucentis (ranibizumab), Byooviz (ranibizumab), Cimerli (ranibizumab-eqrn) Injectable 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), Lupron Depot-PED (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), MARGENZA (margetuximab-cmkb) Medication Precertification request (PDF), Makena (hydroxyprogesterone caproate) 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 Request (PDF), Naglazyme (galsulfase) Medication Precertification request (PDF), Natpara (parathyroid hormone) Medication Precertification request (PDF), Nexviazyme (avalglucosidase alfa-ngpt) Medication Precertification Request (PDF), Nucala (mepolizumab) Injectable Medication Precertification Request (PDF), Nulibry (fosdenopterin) Medication Precertification request (PDF), Ocrevus (ocrelizumab) Medication Precertification request (PDF), Octreoti de acetate injection, Sandostatin, Sandostatin, LAR Depot or Bynfezia Pen Medication Precertification request (PDF), Onpattro (patisiran) Injectable Medication Precertification request (PDF), Opdivo (nivolumab) Injectable Medication Precertification request (PDF), Opdualag (nivolumab and relatlimab-rmbw) Medication Precertification request (PDF), Orencia (abatacept) IV Precertification request (PDF), Oxlumo (lumasiran) Medication Precertification request (PDF), Padcev (enfortumab vedotin-ejfv) Medication Precertification request (PDF), Parsabiv (etelcalcetide) Medication Precertification request (PDF), Pegfilgrastim (Neulasta, Fulphila, Udenyca, Ziextenzo) Precertification request (PDF), Perjeta (pertuzumab) Precertification request (PDF), Pepaxto (melphalan flufenamide) Medication Precertification request (PDF), Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf) Medication Precertification request (PDF), Radicava (edaravone) Medication Precertification request (PDF), Reblozyl (luspatercept-aamt) Medication Precertification Request (PDF), Remicade (infliximab) Injectable Precertification request (PDF), Remodulin (treprostinil) Medication Precertification request (PDF), Renflexis (infliximab-abda) Injectable Medication Precertification request (PDF), Riabni (rituximab-arrx) Medication Precertification request (PDF), Rituxan Hycela (rituximab and hyaluronidase) Medication Precertification request (PDF), Rituxan (rituximab) Precertification request (PDF), Ruconest (C1 esterase inhibitor, recombinant) Medication Precertification Request (PDF), Ruxience (rituximab-pvvr) Medication Precertification request (PDF), Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) Medication Precertification Request (PDF), Ryplazim (plasminogen, human-tvmh) Medication Precertification Request (PDF), Saphnelo (anifrolumab-fnia) Injectable 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) Infusion Medication Precertification request (PDF), Soliris (eculizumab) Injectable Medication Precertification request (PDF), Somatuline Depot (lanreotide) Medication Precertification request (PDF), Somavert (pegvisomant) Medication Precertification request (PDF), Spinraza (nusinersen) Injectable Precertification request (PDF), Spravato (esketamine) Medication Precertification request (PDF), Stelara (ustekinumab) IV Specialty Medication Precertification request (PDF), Strensiq (asfotase alfa) Injectable Medication Precertification request (PDF), SUSVIMO (ranibizumab) 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), Tezspire (tezepelumab-ekko) Medication Precertification request (PDF), TIVDAK (tisotumab vedotin-tftv) Medication Precertification request (PDF), Trelstar (triptorelin pamoate) Medication Precertification request (PDF), Trodelvy (sacituzumab govitecan-hziy) Medication Precertification request (PDF), Truxima (rituximab-abbs) Medication Precertification request (PDF), Tysabri (natalizumab) Medication Precertification request (PDF), Tyvaso (treprostinil inhalation solution) Medication Precertification request (PDF), Ultomiris (ravulizumab-cwvz) Precertification request (PDF), Uplizna (inebilizumab-cdon) Medication Precertification request (PDF), VABYSMO (faricimab-svoa) Injectable Medication Precertification request (PDF), Vectibix (panitumumab) Injectable Medication Precertification request (PDF), Viltepso (viltolarsen) Medication Precertification request (PDF), Ventavis (iloprost inhalation solution) Medication Precertification request (PDF), Vimizim (elosulfase alfa) Medication Precertification request (PDF), Vyepti (eptinezumab-jjmr) Medication Precertification request (PDF), Vyondys 53 (golodirsen) Injectable Medication Precertification request (PDF), Vyvgart (efgartigimod alfa-fcab) Medication Precertification Request (PDF), Xenpozyme (olipudase alfa-rpcp) Medication Precertification Request (PDF), Xeomin (incobotulinumtoxinA) Injectable Medication Precertification request (PDF), Xgeva (denosumab) Injectable Medication Precertification Request (PDF), Xolair (omalizumab) Medication Precertification request (PDF), Yervoy (ipilimumab) Injectable Medication Precertification request (PDF), Zoladex (goserelin acetate) Medication Precertification Request (PDF), Zulresso (brexanolone) Medication Precertification request (PDF), Specialty Medication Precertification request (PDF), Zynteglo (betibeglogene autotemcel) Medication Precertification Request (PDF), Connecticut Accident Detail Questionnaire (PDF), Hawaii Notice of Non-Disclosure of Minor Mental Health Care (PDF), Massachusetts Standard Prior Authorization forms, Nevada Step Therapy Prior Authorization form (PDF), New Jersey Claims Determination Appeal application, New Mexico Uniform Prior Authorization form (PDF), Ohio Electronic Funds Transfer (EFT) Opt Out request (PDF), Texas Standard Prior Authorization, Health Care Services request (PDF), Texas Telemedicine and Telehealth Services Reimbursement Policy (PDF), Washington Intent to Use a Substitute Provider (PDF), Washington D.C. 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