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This Clinical Policy Bulletin addresses botulinum toxin for commercial medical plans. For Medicare criteria, seeMedicare Part B Criteria. Note: Requires Precertification: Precertification of botulinum toxin (Botox [onabotulinumtoxinA]; Daxxify [daxibotulinumtoxinA-lanm], Dysport [abobotulinumtoxinA]; ...
For precertification of ipilimumab (Yervoy), call (866) 752-7021 or fax (888) 267-3277. For Statement of Medical Necessity (SMN) precertification forms, see Specialty Pharmacy Precertification.Note: Site of Care Utilization Management Policy applies for ipilimumab (Yervoy). For information on sit...
For Medicare criteria on intravenous Cosentyx, see Medicare Part B Criteria. Note: Precertification of intravenous (IV) secukinumab (IV Cosentyx only) is required of all Aetna participating providers and members in applicable plan designs. For precertification of IV Cosentyx, call (866) 752-7021 o...
For Medicare criteria, see Medicare Part B Criteria. The American Society for Reproductive Medicine (ASRM, 2023) has defined infertility as a "disease, condition, or status characterized by the inability to achieve a successful pregnancy based on a patient’s medical, sexual, and reproductive ...
This Clinical Policy Bulletin addresses vascular endothelial growth factor inhibitors for ocular indications for commercial medical plans. For Medicare criteria, seeMedicare Part B Criteria. Note: Requires Precertification: Precertification of aflibercept [(Eylea), (Eylea HD)], aflibercept-jbvf (Yesafili...
Precertification of immune globulin human intramuscular injection (IGIM) (GamaSTAN) is required of all Aetna participating providers and members in applicable plan designs. For precertification of immune globulin human intramuscular injection (IGIM) (GamaSTAN), call (866) 752-7021 (commercial) or ...
This Clinical Policy Bulletin addresses aducanumab-avwa (Aduhelm) for commercial medical plans. For Medicare criteria, seeMedicare Part B Criteria. Note: Requires Precertification: Precertification of aducanumab-avwa (Aduhelm) is required of all Aetna participating providers and members in applicable pla...
For Medicare criteria, see Medicare Part B Criteria. Note: Requires Precertification: Precertification of nivolumab (Opdivo), nivolumab and hyaluronidase-nvhy (Opdivo Qvantig), and nivolumab and relatlimab-rmbw (Opdualag) is required of all Aetna participating providers and members in applicable ...
This Clinical Policy Bulletin addresses alpha 1-proteinase inhibitors for commercial medical plans. For Medicare criteria, seeMedicare Part B Criteria. Note:Requires Precertification: Precertification of alpha 1-proteinase inhibitors (Aralast NP, Glassia, Prolastin-C, and Zemaira) is required of all ...