Note: Requires Precertification: Precertification of Cetrotide (cetrorelix acetate), ganirelix acetate, Follistim AQ (follitropin beta), Gonal-F (follitropin alfa), Menopur (menotropins), Novarel (chorionic gonadotropin), Pregnyl (chorionic gonadotropin), Ovidrel (choriogonadotropin alfa), and chorion...
Policy Scope of Policy 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 ...
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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...
An “Aetna Breast and Ovarian Cancer Susceptibility Gene Testing Prior Authorization Form” for Breast and Ovarian Cancer Susceptibility Gene Molecular Testing is to be sent along with the Laboratory's Test Requisition Form to Aetna for precertification. Documentation of specific cancer diagnosis in the...
Note: Requires Precertification:Precertification of ustekinumab (Stelara) administered by a healthcare provider is required of all Aetna participating providers and members in applicable plan designs. For precertification of healthcare provider-administered ustekinumab products, call (866) 752-7021 or fax...
Precertification of an infliximab product (Avsola, Inflectra, Remicade, or Renflexis) is required of all Aetna participating providers and members in applicable plan designs. For precertification of Avsola, Inflectra, Remicade, or Renflexis,call (866) 752-7021 or fax (888) 267-3277. For Stateme...
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...
For precertification of IV Cosentyx, 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 commercial plans. For information on site of ...
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 ...