Pbm.aetna.com

Health Insurance Plans Aetna

WebAetna 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 …

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URL: https://pbm.aetna.com/

Covered and non-covered drugs

WebA ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ONETOUCH. For more information …

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Drugs requiring step therapy

WebStep 1: You will have to try one of these generic medications first: Step 2: Before you can try one of these non-preferred brand drugs: These preferred select brand drugs do not require use of a generic first: Selective Serotonin Reuptake Inhibitors (SSRIs) Depression. citalopram escitalopram tab fluvoxamine fluoxetine paroxetine HCI

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Formulary Exception/Prior Authorization Request Form

Web106-37207A 031824 Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members’ private health information.

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Call out. Contact information, call X-XXX-XXX-XXXX or visit

WebAetna Specialty Pharmacy 503 Sunport Lane Orlando, FL 32809. Phone: 1-866-782-ASRX (1-866-782-2779), option 2. If you mail in your own prescription, please send it with a completed Patient Profile Form. To find this form, just visit the website that’s on your member ID card, to search for the “Patient Profile Form.”.

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1. Patient information 2. Prescriber / Provider information

Web1. Patient information 2. Prescriber / Provider information. 440-4992 5/15/COM)1. Plan name: Is this request Address: City: State: ZIP: Phone: - - Fax: - - Email: …

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Florida Prior Authorization Form

WebPrior Authorization Form for Medical Procedures, Courses of Treatment, or Prescription Drug Benefits If you have questions about our prior authorization requirements, please …

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West Virginia Formulary Exception/Prior Authorization …

WebPRESCRIPTION BENEFIT PLAN MAY REQUEST ADDITIONAL INFORMATION OR CLARIFICATION, IF NEEDED, TO EVALUATE REQUESTS. PLEASE FAX …

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Reject Codes Provider Manual Appendix B

WebØ2 M/I Version/Release Number 1Ø2‐A2 Ø3 M/I Transaction Code 1Ø3‐A3 Ø4 M/I Processor Control Number 1Ø4‐A4 Ø5 M/I Service Provider Number

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Illinois Uniform Electronic Prior Authorization Request Form …

WebThis form is made available for use by prescribing providers to initiate a prior authorization request with a commercial health insurance issuer ("insurer") regulated by the Illinois …

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MASSACHUSETTS STANDARD FORM FOR HEPATITIS C …

Web2 Massachusetts Collaborative — Massachusetts Standard Form for Hepatitis C Medication Prior Authorization Requests April 2019 (version 1.0)

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Medicare Part D: Prescription Claim Form Important!

WebSTEP 3. Provide any Additional Comments or Information Here: Please remember that completing this form is not a guarantee that you’ll be reimbursed. IMPORTANT REMINDER–To avoid having to submit a paper claim form: • Always have your prescription card available at time of purchase. • Use medication from your formulary list.

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