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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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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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 …

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Health Care Insurer Appeals Process Information Packet

WEB1 Eff. Sept. 2013 For Appeal Requests for State of Arizona handled by CVS Caremark – submit requests via fax to 866-443-1172 Health Care Insurer Appeals Process …

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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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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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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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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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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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Prior Authorization Criteria Form

WEBPrior Authorization Form Namenda This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date.

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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 …

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PRESCRIPTION DRUG PRIOR AUTHORIZATION OR STEP …

WEBPlease fill out all applicable sections on both pages completely and legibly . Attach any additional documentation that is important for the review, e.g. chart notes or lab data, to …

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