Precertification of botulinum toxin (Botox [onabotulinumtoxinA]; Daxxify [daxibotulinumtoxinA-lanm], Dysport [abobotulinumtoxinA]; Myobloc [rimabotulinumtoxinB]; and Xeomin [incobotulinumtoxinA]) is required of all Aetna participating providers and members in applicable plan designs. For precertif...
This Clinical Policy Bulletin addresses infliximab for commercial medical plans. For Medicare criteria, seeMedicare Part B Criteria. Note: Requires Precertification: Precertification of an infliximab product (Avsola, Inflectra, Remicade, or Renflexis) is required of all Aetna participating providers and ...
Precertification of aflibercept [(Eylea), (Eylea HD)], aflibercept-jbvf (Yesafili), aflibercept-mrbb (Ahzantive), aflibercept-yszy (Opuviz), brolucizumab-dbll (Beovu), faricimab-svoa (Vabysmo), ranibizumab (Lucentis), ranibizumab (Susvimo), ranibizumab-eqrn (Cimerli), and ranibizumab-n...
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 plan designs. For precertification of nivolumab (Opdivo), nivolumab and hyaluronidase-nv...
Note: Requires Precertification: Precertification of testosterone undecanoate injection (Aveed) is required of all Aetna participating providers and members in applicable plan designs. For precertification of testosterone undecanoate injection (Aveed), call (866) 752-7021 or fax (888) 267-3277. For ...
Precertification of long-acting granulocyte colony stimulating factor (G-CSF) products [Fulphila (pegfilgrastim-jmdp); Fylnetra (pegfilgrastim-pbbk); Neulasta (pegfilgrastim); Nyvepria (pegfilgrastim-apgf); Rolvedon (eflapegrastim-xnst), Ryzneuta (efbemalenograstim alfa-vuxw), Stimufend (pegfil...
Precertification of certolizumab pegol (Cimzia) is required of all Aetna participating providers and members in applicable plan designs. For precertification, call (866) 752-7021 or fax (888) 267-3277. For Statement of Medical Necessity (SMN) precertification forms, see Specialty Pharmacy Precertif...
Note: Requires Precertification: Precertification of pembrolizumab (Keytruda) is required of all Aetna participating providers and members in applicable plan designs. For precertification, call (866) 752-7021 or fax (888) 267-3277. For Statement of Medical Necessity (SMN) precertification forms, se...
Precertification of omalizumab (Xolair) is required of all Aetna participating providers and members in applicable plan designs. For precertification of omalizumab call (866) 752-7021 or fax (888) 267-3277. For Statement of Medical Necessity (SMN) precertification forms, see Specialty Pharmacy Pre...
For precertification of teprotumumab-trbw (Tepezza), 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 teprotumumab-trbw (Tepezza)....