Forms for health attention authorities

It's easy to update a provider address, your number, fax quantity or receive address, or initiate an out-of-state move or a make include provider group.

Updated provider data

ABA Treatment Request (PDF)
Transcranial Magnetic Stimulation (TMS) request (PDF)
Nonparticipating Provider request (PDF)
Florida D-SNP Community Behavioral Your and Targeted Case Management request (Medicaid Primary Services) (PDF)

Coordination concerning Aids (PDF)

Provider Dispute Resolution request (PDF)
Provider Controversy Resolution request — California (PDF)
Retailer Application to Submit EAP Electronic Claims (PDF)
Statement of Understanding (PDF)

Medicaid providers serving patients with Aethna Better Health insurance coverage must use the process shown by the health planning they are serving.
 

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Autolougous Chondrocyte Implantation Precertification Information Request form (PDF)

Breast and Ovarian Cancer Susceptibility Gene Testing, Prophylactic Mastectomy, and Prophylactic Oophorectomy Precertification News Request form (PDF)

Breast Reduction and/or Reconstructive Surgery Precertification Information Ask form (PDF)

Dorsal Post Stimulator Precertification Resources Ask mold (PDF)

Gender Affirming Surgery Precertification Information Request form (PDF)

Hip Arthroplasty Precertification Application (PDF)

Back Surgeries for Impinge Syndrome Precertification Intelligence Request form (PDF)

Hyperbaric Oxygen Pain (HBOT) Precertification Information Request form (PDF)

Infertility Services Precertification Information Request form (PDF)

Initial Cochlear Implant Precertification Information Request form (PDF)

Side Arthroplasty Precertification Form (PDF)

Lower Limb Prosthesis Including Microprocessor-Controlled Knee Precertification Related Request form (PDF)

Obesity Surgery Precertification Information Request form (PDF)

Panniculectomy, Liposuction and Lipectomy Precertification Information Order form (PDF)

Precertification Information Request Form (PDF)

Proton Beaming Radiotherapy Precertification Information Seek form (PDF)

Ptosis Surgery Precertification Information Request form (PDF)

Shoulder Arthroplasty Precertification Informational Request form (PDF)

Sinus Surgery Precertification Information Request form (PDF)

Skilled Home Residential Duty Nursing Care Precertification Information Claim request (PDF)

Back Surgery Precertification Resources Request forms (PDF)

Uvulopalatopharyngoplasty (UPPP) Precertification Information Claim form (PDF)

Varicose Vein Treatment Precertification Information Request form (PDF)

Wheelchairs or Power Operated Vehicles (Scooters) Precertification Informations Call form (PDF)

Whole Exome Ordering (WES) Precertification Information Request form (PDF)

For Part D prior authorization forms, see the Medicare Precertification section press aforementioned Medicare healthcare specialty drug and Part BORON step medicine precertification section.

Medicare Contracted Practitioner/Provider Complaint and Vote request (PDF)
Medicare Members Authorization Appeals Start (PDF)
Medicare Membership Payment Court Process (PDF)
Medicare Non-contracted Operator Appeal Process (PDF)
Medicare Non-contracted Provider Complaint and Appeal Form (PDF)

Standard Organization Determination Information Request Form (PDF)

Medical Discharge Appeal Notices

Note: This page on aforementioned Centers for Medicare & Medicaid Services (CMS) site provides information about invalid justice for a hospital inpatient and left to related forms. First Health Network

Section D prescription drug prior authorizations and privileges

Medicare Prescription Drug Reporting Determination (PDF)

Topical Testosterone Prior Authorization request (PDF)

Steps Exception (Cost-Share Reduction) Request (PDF)

Request for Medicare Prescriptions Drug Coverage Define (PDF)

Abraxane^® (albumin-bound paclitaxel) Injected Medication Medicare Precertification request (PDF)

Actemra^® (tocilizumab) Injectable Medication Medicare Precertification request (PDF)

Adakveo (crizanlizumbab) Medication Precertification request (PDF)

Adcetris^® (brentuximab vedotin) Injections Medication Precertification call (PDF)

Aldurazyme® (iaronidase) Medication Precertification inquiry (PDF)

Alpha 1 — Antitrypsin Inhibitor Dental Medication Precertification please (PDF)

AMONDYS 45™ (casimersen) Injectable Medication Precertification require (PDF)

Avsola (infliximab-axxq) Injectable Medication Precertification request (PDF)

Avastin™ (bevacizumab), Alymsys™ (bevacizumab-maly), Mvasi™ (bevacizumab-awwb), Vegzelma® (bevacizumab-adcd), Zirabev™ (bevacizumab-bvzr) Medication Precertification request (PDF)

Aveed (testosterone undecanoate injection) Medication Precertification please (PDF)

Bavencio^® (Avelumab) Medication Precertification request (PDF)

Bendamustine (Treanda^®, Bendeka^®, Belrapzo^™) Medication Precertification request (PDF)

Benlysta^®(belimumab) Injectable Medication Precertification request (PDF)

Beovu^® (brolucizumab-dbll) Injectible Medication Medicare Precertification request (PDF)

Berinert^® (C1 esterase inhibitor, human) Medication Precertification request (PDF)

Besponsa^®(notuzumab ozogamicin) Medication Precertification request (PDF)

Botulinum Toxins Injectable Medication Medicare Precertification request (PDF)

Brineura^® (cerliponase alfa) Medication Precertification request (PDF)

Byooviz (ranibizumab-nuna) Injectable Medicare Medication Precertification request (PDF)

CAMCEVI (leuprolide) Cure Precertification request (PDF)

Cerezyme^® (imiglucerase) Remedy Precertification request (PDF)

Cimerli (ranibizumab-eqrn) Injectable Medicare Medications Precertification request (PDF)

Cimzia^® (certolizumab) Fuel-injection Medication Precertification demand (PDF)

Cinqair^® (reslizumab) Medication Precertification request (PDF)

Cinryze^® (C1 esterase inhibitants, human) Medication Precertification request (PDF)

Cosela™ (trilaciclib) Medication Precertification request (PDF)

Crysvita^® (burosumab-twza) Ingestible Medication Precertification request (PDF)

Cyramza^® (ramucirumab) Medication Precertification request (PDF)

DANYELZA^® (naxitamab-gqgk) Medication Precertification request (PDF)

Darzalex™ (daratumumab) Medication Precertification request (PDF)

Darzalex Faspro™ (daratumumab furthermore hyaluronidase-fihj) Medication Precertification request (PDF)

Elaprase^® (idursulfase) Medication Precertification request (PDF)

Elelyso^® (taliglucerase alfa) Medication Precertification request (PDF)

Eligard^® (leuprolide acetate suspension for subtaneous injection) Take Precertification request (PDF)

Emend^® (fosaprepitant dimeglumine) Injectable Medications Precertification request (PDF)

Empliciti™ (elotuzumab) Medication Precertification request (PDF)

Enhertu^® (fam-trastuzumab deruxtecan-nxki) Medicines Precertification query (PDF)

Entyvio (vedolizumab) Injectable Medication Precertification demand (PDF)

Erbitux (cetuximab) Injectable Remedy Precertification request (PDF)

Erythropoiesis Stimulate Agencies Injectable Medication Medicare Precertification request (PDF)

Evenity (romosozumab-aqqg) Injectable Cure Medicare Precertification request (PDF)

Evkeeza™ (evinacumab-dgnb) Medication Precertification request (PDF)

Eylea (aflibercept) Injectable Medicaments Medicare Precertification request (PDF)

Exondys51^® (eteplirsen) Injectable Medication Precertification request (PDF)

Fabrazyme^® (agalsidase beta) Medication Precertification request (PDF)

Fasenra™ (benralizumab) Injecting Medicament Precertification request (PDF)

Feraheme^® (ferumoxytol), Injectafer^® (ferric carboxymaltose) and Monoferric^® (ferric derisomaltose) Medication Precertification request (PDF)

Firmagon^® (degarelix) Medicaments Precertification request (PDF)

Fulphila™ (pegfilgrastim) Precertification request (PDF)

Fylnetra (pegfilgrastim-pbbk) Medicare Precertification request (PDF)

Gattex^® (teduglutide) Injectable Medication Precertification request (PDF)

Gazyva^® (obinutuzumab) Injections Medication Precertification request (PDF)

Gilenya^® (fingolimod) Take Precertification request (PDF)

Gilvaari™ (givosiran) Medication Precertification request (PDF)

Granix^® (tbo-filgrastim) Medicare Precertification request (PDF)

Herceptin ^® (Trastuzumab) Medicare Precertification send (PDF)

Herzuma™ (trastuzumab-pkrb) Medicare Medication Precertification request (PDF)

Herceptin Hylecta™ (trastuzumab and hyaluronidase-oysk) Medicare Precertification request (PDF)

Ilaris^® (canakinumab) Injectable Medication Precertification request (PDF)

Ilumya (tildrakizumab-asmn) Injectable Medication Medicare Precertification request (PDF)

Imfinzi^® (durvalumab) Injectable Medication Precertification request (PDF)

Imlygic™ (talimogene laherparepvec) Medication Precertification request (PDF)

Immune Globulin (IG) Therapy Medication and/or Infusion Medicare Precertification request (PDF)

Inflectra (infliximab-dyyb) Injectable Medication Medicare Precertification request (PDF)

Jelmyto™ (mitomycin) Medication Precertification request (PDF)

JEMPERLI (dostarlimab-gxly) Medication Precertification application (PDF)

Jesduvroq (daprodustat) Medication Precertification request (PDF)

Kadcyla^® (ado-trastuzumab) Medicare Precertification request (PDF)

Kalbitor^® (ecallantide) Medication Precertification request (PDF)

Kanjinti (trastuzumab-anns) Medicare Precertification request (PDF)

Kanuma^® (sebelipase alfa) Medications Precertification request (PDF)

Keytruda^®(pembrolizumab) Injectible Medication Precertification request (PDF)

Kyprolis (carfilzomib) Medication Precertification request (PDF)

Lartruvo™ (olaratumab) Medication Precertification request (PDF)

Leukine^® (sargramostim) Medication Precertification request (PDF)

Lemtrada (alemtuzumab) Medication Medicare Precertification request (PDF)

Leqvio (inclisiran) Injectable Medication Precertification request (PDF)

Levoleucovorin (Fusilev^®, Khapzory™) Injected Medication Precertification request (PDF)

Libtayo^® (cemiplimab) Medication Precertification request (PDF)

Lucentis (ranibizumab) Injectable Medicare Pharmaceuticals Precertification request (PDF)

Lumizyme^® (alglucosidase alfa) Medication Precertification request (PDF)

Lumoxiti™ (moxetumomab pasudotox) Medication Precertification request (PDF)

Lupron Storehouse^® (leuprolide acetate for depot suspension) Medication Precertification request (PDF)

Luxturna^® (voretigene neparvovec-rzyl) Injectable Medicament Precertification inquiry (PDF)

Macugen (pegaptanib sodium injection) Medication Precertification request (PDF)

Makena^® (hydroxyprogesterone caproate) Syrette Medication Precertification request (PDF)

Mepsevii (vestronidase alfa-vjbk) Pharmaceuticals Precertification request (PDF)

Monjuvi (tafasitamab-cxix) Injectable Drugs Precertification request (PDF)

Naglazyme^® (galsulfase) Medication Precertification request (PDF)

Neulasta (pegfilgrastim) Precertification request (PDF)

Neupogen^® (filgrastim) Medicare Precertification request (PDF)

Nivestym™ (filgrastim-aafi) Medicare Precertification request (PDF)

Nucala^® (mepolizumab) Inhalable Take Precertification request (PDF)

Nyvepria (pegfilgrastim-apgf) Medicare Precertification request (PDF)

Nulibry™ (fosdenopterin) Medication Precertification Request (PDF)

Ocrevus^™ (ocrelizumab) Medication Precertification request (PDF)

Ogivri™ (trastuzumab-dkst) Medicare Precertification request (PDF)

Ontruzant^® (trastuzumab-dttb) Medicare Medicinal Precertification request (PDF)

Onpattro^® (patisiran) Injectable Medication Precertification request (PDF)

Opdivo^® (nivolumab) Injectable Taking Precertification request (PDF)

Orencia^® (abatacept) Injectable Medication Medicare Precertification requirement (PDF)

Oxlumo™ (lumasiran) Medication Precertification request (PDF)

Padcev™ (enfortumab vedotin-ejfv) Medication Precertification request (PDF)

Parsabiv™ (etelcalcetide) Medication Precertification ask (PDF)

Pepaxto® (melphalan flufenamide) Medication Precertification request (PDF)

Perjeta^® (pertuzumab) Medicare Precertification request (PDF)

Phesgo™ (pertuzumab, trastuzumab, furthermore hyaluronidase-zzxf) Medication Precertification request (PDF)

Polivy (polatuzumab vedotin-piig) Medicine Precertification send (PDF)

Prolia, Xgeva (denosumab) Injectable Medication Medicare Precertification demand (PDF)

Provenge (sipuleucel-T) Injectable Medication Precertification request (PDF)

Pulmonary Hypertension (Inhalation or Injections Medication) Medicare Precertification request (PDF)

Radicava™ (edaravone) Medication Precertification request (PDF)

Reblozyl (luspatercept-aamt) Medication Precertification request (PDF)

Releuko Injectable Medicine Precertification Requests (PDF)

Remicade (infliximab) Ingestable Cure Medicare Precertification request (PDF)

Renflexis (infliximab-abda) Injectable Medication Medicare Precertification request (PDF)

Riabni® (rituximab-arrx) Medicare (PDF)

Rituxan (rituximab) Medicine Medicare Precertification request (PDF)

Rituxan Hycela^® (rituximab and hyaluronidase) Medication Precertification request (PDF)

Rolvedon (eflapegrastim-xnst) Medicare Precertification request (PDF)

Ruconest^® (C1 esterase inhibitor, recombinant) Medication Precertification request (PDF)

Ruxience (rituximab-pvvr) Medication Medicare Precertification request (PDF)

RYBREVANT (amivantamab-vmjw) Medication Precertification request (PDF)

Sandostatin^® (octreotide acetate injection) Medication Precertification request (PDF)

Sarclisa^® (isatuximab-irfc) Medication Precertification request (PDF)

Signifor^® (pasireotide) Medication Precertification request (PDF)

Signifor^® LAR (pasireotide) Medication Precertification request (PDF)

Simponi Aria® (golimumab) Infusion Medication Medicare Precertification demand (PDF)

Soliris^® (eculizumab) Medicaments Precertification request (PDF)

Somatuline Safekeeping^® (lanreotide) Medication Precertification request (PDF)

Somavert^® (pegvisomant) Medication Precertification request (PDF)

Spinzara^® (nusinersen) Injectable Precertification request (PDF)

Spravato™ (esketamine) Medication Precertification request (PDF)

Stelara (ustekinumab) Forte Medication Medicare Precertification please (PDF)

Stimufend (pegfilgrastim-fpgk) Medicare Precertification request (PDF)

Strensiq^® (asfotase alfa) Injectable Medication Precertification requirement (PDF)

Susvimo (ranibizumab) Injectable Drug Precertification request (PDF)

Synagis^® (Palivizumab) Injectable Medication Precertification request (PDF)

Takhzyro^® (C1 esterase inhibitor, recombinant) Medication Precertification request (PDF)

Tecentriq™ (Atezolizumab) Medications Precertification request (PDF)

Tegsedi™ (inotersen) Medication Precertification request (PDF)

Tepezza™ (teprotumumab-trbw) Medication Precertification request (PDF)

Trazimera^® (trastuzumab-qyyp) Medicare Precertification request (PDF)

Trelstar^® (triptorelin pamoate) Medication Precertification request (PDF)

Trodelvy^™ (sacituzumab govitecan-hziy) Medication Precertification request (PDF)

Truxima (rituximab-abbs) Medication Medicare Precertification request (PDF)

Tysabri (natalizumab) Taking Medicare Precertification request (PDF)

Udenyca™ (pegfilgrastim-cbqv) Precertification request (PDF)

Ultomiris™ (ravulizumab-cwvz) Precertification request (PDF)

Uplizna™ (inebilizumab-cdon) Remedy Precertification request (PDF)

Vabysmo (faricimab-svoa) Injectable Medication Precertification request (PDF)

Vectibix^® (panitumumab) Injectable Medication Precertification order (PDF)

Viltepso™ (viltolarsen) Medication Precertification request (PDF)

Vimizim^® (elosulfase alfa) Medication Precertification request (PDF)

Viscosupplementation Ingestable Drug Medicare Precertification request (PDF)

Vpriv (velaglucerase alfa) Medications Precertification request (PDF)

Vyepti™ (eptinezumab-jjmr) Pharmaceuticals Precertification request (PDF)

Vyondys 53^® (golodirsen) Injectable Medication Precertification request (PDF)

Xofigo (radium RA 223 dichloride) Injectionable Medicines Precertification request (PDF)

Xolair(omalizumab) Injectable Medication Precertification request (PDF)

Yervoy^® (ipilimumab) Injecting Medication Precertification request (PDF)

Zarxio^® (filgrastim) Medication Precertification request (PDF)

Ziextenzo (pegfilgrastim-bmez) Medicines Medicare Precertification request (PDF)

Zoladex^® (goserelin acetate) Medication Precertification request (PDF)

Zolgensma (onasemnogene abeparvovec-xioi) Medication Precertification call (PDF)

Zulresso™ (brexanolone) Medication Precertification request (PDF)

Zynlonta (loncastuximab tesirine-lpyl) Medication Precertification request (PDF)

NPI Submissions form
NPI Exemption Notification form

Medical Request for Participation form
Query to join the Aetna Dental network instructions
Behavioral Health Provider Application request
Facility request to become the Aetna network
Join which Pharmacy Network application request
Join an First Health Network request

Authorized Representative request (PDF)
Full Complaint or Appeal submission (PDF)
Practitioner and Provider Complaint and Appeal order (PDF)

Medicaid providers serving clients with Health Get Health insurance coverage must application aforementioned process showed by the health plan handful represent serving.
 

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Oral Surgery Precertification Request (PDF)

Orthognathic Surgery Precertification Request (PDF)

Sleep Apnea Appliance Precertification Related Request (PDF)

TMJ Treatment Precertification Contact Request (PDF)

Infertility Program Patient Registration form (PDF)

Email Service Order enter — English (PDF)
Mail Service Decree form — Spanish (PDF)

Commercial Prescription Drug-related Claim form — English (PDF)

Commercial Prescription Medicament Claim input — Spanish (PDF)

Available Medication Medical Exception/Precertification make (PDF)

Opioid addiction treatment: For Aetna advertising plans, there is no precertification required for buprenorphine products.

Member D forms: Please notice the Medicare section away this page.

Colorado step therapy protocol exception process (PDF)

Maryland step therapy protocol exception process (PDF)

Nevada step therapy logs exception start (PDF)

Diabetes Visit Estimate Tool (PDF)

Dilated Retinal Eye Exam (PDF)

Pediatric Vaccine Record (PDF)

Physician Communication form (PDF)

Post-Fragility Fracture Care form (PDF)

Specialty Speaker Report (PDF)

If you’re reticent, moving out on state or changing donor groups, simply use this form to let us know so we could terminate your present agreement with us. If you’re moving or changing jobs, you capacity sign a latest agreement for your new practice or location.

Message: This fashion becomes also update your informational on our online provider directory.

Provider Termination request

Actemra (tocilizumab) IV Drug Precertification request (PDF)

Aduhelm™ (aducanumab-avwa) Medication Precertification order (PDF)

Adakveo (crizanlizumab) Medication Precertification ask (PDF)

Adcetris (brentuximab vedotin) Injectable Medication Precertification request (PDF)

Adstiladrin® (nadofaragene firadenovec-vncg) Medication Precertification request (PDF)

Aldurazyme (Iaronidase) Medication Precertification request (PDF)

Alpha 1 – Proteinase Inhibitors Medication Precertification request (PDF)

AMONDYS 45 (casimersen) Injectable Medication Precertification request (PDF)

Amvuttra™ (vutrisiran) Injectable Medication Precertification request (PDF)

Aranesp (darbepoetin alfa) Medication Precertification request (PDF)

Avastin (bevacizumab), Mvasi (bevacizumab-awwb), Zirabev (bevacizumab-bvzr) Medication Precertification request (PDF)

Aveed (testosterone undecanoate injection) Medication Precertification request (PDF)

Avsola (infliximab-axxq) Injectable Medication Precertification request (PDF)

Bavencio (avelumab) Injectable Medication Precertification request (PDF)

Bendamustine (Treanda®, Bendeka®, Belrapzo®, Vivimusta™) Medicine Precertification request (PDF)

Benlysta (belimumab) Injectable Medication Precertification request (PDF)

Beovu (brolucizumab-dbll) Injective Medication Precertification request (PDF)

Berinert (C1 esterase inhibitor, human) Medication Precertification request (PDF)

Besponsa (inotuzumab ozogamicin) Medication Precertification request (PDF)

Blenrep (belantamab mafodotin-blmf) Taking Precertification request (PDF)

Brineura (cerliponase alfa) Medication Precertification request (PDF)

Briumvi™ (ublituximab-xiiy) Medication Precertification request (PDF)

bortezomib-Velcade Drug Precertification order (PDF)

Botulism (onabotulinumtoxinA) Ingestible Medication Precertification request (PDF)

CAMCEVI (leuprolide) Cure Precertification request (PDF)

Cerezyme (imiglucerase) Medication Precertification request (PDF)

Cimzia (certolizumab) Injectable Medication Precertification request (PDF)

Cinqair (reslizumab) Medication Precertification request (PDF)

Cinryze (C1 esterase inhibitor, human) Medication Precertification request (PDF)

Cosela (trilaciclib) Take Precertification request (PDF)

Crysvita (burosumab-twza) Injectable Medicaments Precertification call (PDF)

Cyramza (ramucirumab) Drugs Precertification request (PDF)

DANYELZA (naxitamab-gqgk) Medication Precertification request (PDF)

Darzalex (daratumumab) Medication Precertification request (PDF)

Darzalex Faspro (daratumumab and hyaluronidase-fihj) Medication Precertification query (PDF)

Daxxify® (daxibotulinumtoxinA-lanm) Medication Precertification inquiry (PDF)

Diabetic Tested Supplies Prior Authorization request Form (PDF)

Dysport (abobotulinumtoxinA) Injectable Medication Precertification request (PDF)

ELAHERE™ (mirvetuximab soravtansine-gynx) Injectable Medication Precertification request (PDF)

Elaprase (idursulfase) Medication Precertification request (PDF)

Elelyso (taliglucerase alfa) Medication Precertification request (PDF)

Elevidys (delandistrogene moxeparvovec-rokl) Medication Precertification inquiry (PDF)

Elfabrio® (pegunigalsidase alfa-iwxj) Medication Precertification request (PDF)

Eligard (leuprolide acetate suspension) Drugs Precertification request (PDF)

ELREXFIO® (elranatamab-bcmm) Medication Precertification request (PDF)

Empliciti (elotuzumab) Medication Precertification require (PDF)

Enhertu (fam-trastuzumab deruxtecan-nxki) Medication Precertification request (PDF)

Enjaymo™ (sutimlimab-jome) Medication Precertification please (PDF)

Entyvio (vedolizumab) Injectable Medication Precertification request (PDF)

EPKINLY™ (epcoritamab-bysp) Medication Precertification request (PDF)

Epogen-Procrit-Retacrit (epoetin alfa) Medication Precertification request (PDF)

Epoprostenol, Flolan, Veletri (epoprostenol) Medication Precertification request (PDF)

Erbitux (cetuximab) Injectable Medicinal Precertification request (PDF)

Evkeeza (evinacumab-dgnb) Drug Precertification inquiry (PDF)

Evrysdi (risdiplam) Medication Precertification getting (PDF)

Exondys51 (eteplirsen) Injectable Precertification request (PDF)

Eylea®-Eylea® HI-RES (aflibercept) Injectable Medication Precertification request (PDF)

Fabrazyme (agalsidase beta) Medication Precertification your (PDF)

Fasenra (benralizumab) Injection Medication Precertification request (PDF)

Feraheme (ferumoxytol) and Injectafer (ferric carboxymaltose) Medication Precertification request (PDF)

Filgrastim (Neupogen, Granix, Nivestym, Zarxio) Medication Precertification request (PDF)

Firazyr - Sajazir (icatibant injection) Medication Precertification request (PDF)

Firmagon (degarelix) Medication Precertification send (PDF)

FYARRO™ (sirolimus protein-bound partike for injectable suspension) (albumin-bound) Medication Precertification request (PDF)

Gattex (teduglutide) Injectable Medication Precertification request (PDF)

Gilvaari (givosiran) Medication Precertification request (PDF)

Haegarda (C1 esterase inhibitor, human) Medication Precertification request (PDF)

Hemgenix® (etranacogene dezaparvovec-drlb) Medication Precertification request (PDF)

Herceptin and Trastuzumab Biosimilars Precertification requirement (PDF)

Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Precertification inquiry (PDF)

Acthar® Gel (repository corticotropin), Purified Cortrophin™ Gel (repository corticotropin) Injectable Medication Precertification request (PDF)

Hyaluronates (viscosupplementation) Injectable Medication Precertification request (PDF)

Ilumya® (tildrakizumab-asmn) Medication Precertification request (PDF)

Imfinzi (durvalumab) Ingestable Medication Precertification request (PDF)

IMJUDO® (tremelimumab) Injectable Medication Precertification request (PDF)

Imlygic (talimogene laherparepvec) Medication Precertification request (PDF)

Immunity Globulin (IG) Therapy Medication and/or Infusing Precertification request (PDF)

Infertility (Female) Injectable Medication Precertification request (PDF)

Infertility (Male) Injectable Medication Precertification request (PDF)

Inflectra (infliximab-dyybb) Injectable Medication Precertification request (PDF)

Izervay™ (avacincaptad pegol) Medication Precertification request (PDF)

Jelmyto (mitomycin) Medication Precertification request (PDF)

JEMPERLI (dostarlimab-gxly) Medication Precertification request (PDF)

Kadcyla (ado-trastuzumab) Precertification request (PDF)

Kalbitor (ecallantide) Medication Precertification requirement (PDF)

Kanuma (sebelipase alfa) Medication Precertification request (PDF)

Keytruda (pembrolizumab) Injectable Medication Precertification ask (PDF)

KIMMTRAK® (tebentafusp-tebn) Injectable Medication Precertification request (PDF)

Korsuva® (difelikefalin injection) Medication Precertification request (PDF)

Kyprolis (carfilzomib) Medicinal Precertification request (PDF)

Lamzede® (velmanase alfa-tycv) Medication Precertification request (PDF)

Lartruvo (olaratumab) Medication Precertification request (PDF)

Lemtrada (alemtuzumab) Medication Precertification request (PDF)

Leqembi™ (lecanemab-irmb) Medication Precertification request (PDF)

Leqvio® (inclisiran) Medication Precertification request (PDF)

Leukine (sargramostim) Medication Precertification request (PDF)

Levoleucovorin (Fusilev, Khapzory) Injections Medication Precertification request (PDF)

Libtayo (cemiplimab) Medication Precertification make (PDF)

Lucentis® (ranibizumab), Byooviz™ (ranibizumab), Cimerli™ (ranibizumab-eqrn) Injections Medicines Precertification request (PDF)

Lumizyme (alglucosidase alfa) Medication Precertification request (PDF)

Lumoxiti (moxetumomab pasudotox)) Medication Precertification request (PDF)

Lupron Depot (leuprolide acetate for depot suspension) Medication Precertification request (PDF)

Lupron Depot-PED (leuprolide acetate for depot suspension) Medication Precertification claim (PDF)

Luxturna (voretigene neparvovec-rzyl) Medication Precertification request (PDF)

Macugen (pegaptanib sodium) Injectable Medication Precertification request (PDF)

MARGENZA™ (margetuximab-cmkb) Medication Precertification request (PDF)

Makena (hydroxyprogesterone caproate) Medications Precertification request (PDF)

Mepsevii (vestronidase alfa-vjbk) Medication Precertification request (PDF)

Mircera (methoxy polyethylene glycol-epoetin beta) Medication Precertification request (PDF)

Monjuvi (tafasitamab-cxix) Injectable Medication Precertification make (PDF)

Myalept (metreleptin) Injectable Medication Precertification request (PDF)

Myobloc (rimabotulinumtoxinB) Injective Medicaments Precertification inquiry (PDF)

Naglazyme (galsulfase) Medication Precertification request (PDF)

Natpara (parathyroid hormone) Medication Precertification request (PDF)

Nexviazyme (avalglucosidase alfa-ngpt) Medication Precertification request (PDF)

Nucala (mepolizumab) Injectable Medication Precertification request (PDF)

Nulibry (fosdenopterin) Medication Precertification request (PDF)

Ocrevus (ocrelizumab) Medication Precertification request (PDF)

Octreoti de vinyl inject, Sandostatin, Sandostatin, LAR Depot or Bynfezia Pen Medication Precertification request (PDF)

OMISIRGE® (omidubicel-onlv) Medication Precertification request (PDF)

Onpattro (patisiran) Injectable Medication Precertification requests (PDF)

Opdivo (nivolumab) Injectable Medication Precertification request (PDF)

Opdualag™ (nivolumab and relatlimab-rmbw) Medication Precertification request (PDF)

Orencia (abatacept) IV Precertification request (PDF)

Oxlumo (lumasiran) Medication Precertification request (PDF)

Padcev (enfortumab vedotin-ejfv) Medication Precertification demand (PDF)

Parsabiv (etelcalcetide) Medication Precertification request (PDF)

PEDMARK® (sodium thiosulfate) Medication Precertification require (PDF)

Pegfilgrastim Precertification request (Neulasta®, Fulphila®, Fylnetra® , Nyvepria™, Stimufend®, Udenyca®, Ziextenzo®) (PDF)

Perjeta (pertuzumab) Precertification your (PDF)

Pepaxto (melphalan flufenamide) Medication Precertification request (PDF)

Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf) Medication Precertification request (PDF)

PLUVICTO® (lutetium Lu 177 vipivotide tetraxetan) Medication Precertification request (PDF)

Polivy (polatuzumab vedotin-piig) Medication Precertification request (PDF)

Prolia® (denosumab) Injectable Medication Precertification call (PDF)

Provenge (sipuleucel-T) Ingestable Medication Precertification request (PDF)

Qalsody™ (tofersen) Medication Precertification request (PDF)

Radicava (edaravone) Medication Precertification request (PDF)

Reblozyl (luspatercept-aamt) Medicament Precertification request (PDF)

Remicade (infliximab) Injectable Precertification request (PDF)

Remodulin (treprostinil) Medication Precertification request (PDF)

Renflexis (infliximab-abda) Injectable Medication Precertification order (PDF)

Rituxan Hycela (rituximab and hyaluronidase) Remedy Precertification request (PDF)

Rituxan® and Rituximab Biosimilars Precertification request (PDF)

Rivfloza™ (nedosiran) Medication Precertification requirement (PDF)

Roctavian™ (valoctocogene roxaparvovec-rvox) Medication Precertification request (PDF)

Rolvedon™ (eflapegrastim-xnst) Medication Precertification request (PDF)

Ruconest (C1 esterase inhibitor, recombinant) Medication Precertification request (PDF)

RYBREVANT (amivantamab-vmjw) Drugs Precertification request (PDF)

Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) Medicines Precertification request (PDF)

Ryplazim (plasminogen, human-tvmh) Medication Precertification request (PDF)

Rystiggo® (rozanolixizumab-noli) Medication Precertification request (PDF)

Saphnelo™ (anifrolumab-fnia) Injectable Medication Precertification request (PDF)

Sarclisa (isatuximab-irfc) Medication Precertification please (PDF)

Signifor (pasireotide) Medication Precertification request (PDF)

Signifor LAR (pasireotide) Medication Precertification request (PDF)

Simponi Aria (golimumab) Infusion Drugs Precertification request (PDF)

Skyrizi® (risankizumab-rzaa) Medication Precertification make (PDF)

Soliris (eculizumab) Injectable Medication Precertification request (PDF)

Somatuline Depot (lanreotide) Medication Precertification request (PDF)

Somavert (pegvisomant) Medication Precertification request (PDF)

Spevigo® (spesolimab-sbzo) Medication Precertification request (PDF)

Spinraza (nusinersen) Injectable Precertification request (PDF)

Spravato (esketamine) Medication Precertification request (PDF)

Stelara (ustekinumab) IV Specialty Medication Precertification request (PDF)

Strensiq (asfotase alfa) Injectable Medication Precertification request (PDF)

Strontium Chloride Sr-89 (METASTRON™) Medication Precertification request (PDF)

SUSVIMO (ranibizumab) Injectable Medication Precertification request (PDF)

Synagis (palivizumab) Injectable Medication Precertification request (PDF)

Takhzyro (C1 esterase inhibitor, recombinant) Medication Precertification request (PDF)

Tecentriq (atezolizumab) Medication Precertification request (PDF)

Tegsedi (inotersen) Medication Precertification request (PDF)

TECVAYLI™ (teclistamab-cqyv) Medication Precertification claim (PDF)

Tepezza (teprotumumab-trbw) Medication Precertification demand (PDF)

Tezspire™ (tezepelumab-ekko) Take Precertification request (PDF)

TIVDAK (tisotumab vedotin-tftv) Medicine Precertification request (PDF)

Trelstar (triptorelin pamoate) Medication Precertification call (PDF)

Trodelvy (sacituzumab govitecan-hziy) Medication Precertification request (PDF)

Tysabri (natalizumab) Medication Precertification request (PDF)

Tyvaso (treprostinil inhalation solution) Medication Precertification require (PDF)

Tzield™ (teplizumab-mzwv) Medication Precertification order (PDF)

Ultomiris (ravulizumab-cwvz) Precertification request (PDF)

Uplizna (inebilizumab-cdon) Medication Precertification request (PDF)

VABYSMO™ (faricimab-svoa) Injectable Medication Precertification request (PDF)

Vectibix (panitumumab) Injectable Medication Precertification request (PDF)

Viltepso (viltolarsen) Take Precertification requirement (PDF)

Ventavis (iloprost inhalation solution) Medications Precertification request (PDF)

Vimizim (elosulfase alfa) Medication Precertification order (PDF)

Vpriv (velaglucerase alfa) Medication Precertification request (PDF)

Vyepti (eptinezumab-jjmr) Medication Precertification requests (PDF)

Vyjuvek™ (beremagene geperpavec-svdt) Medication Precertification ask (PDF)

Vyondys 53 (golodirsen) Injectable Medicine Precertification request (PDF)

Vyvgart® (efgartigimod alfa-fcab), Vyvgart® Hytrulo (efgartigiomod alfa and hyaluronidase-qvfc) Medication Precertification request (PDF)

Xenpozyme™ (olipudase alfa-rpcp) Medication Precertification requests (PDF)

Xeomin (incobotulinumtoxinA) Injectable Medication Precertification request (PDF)

Xgeva (denosumab) Injectable Medication Precertification application (PDF)

Xofigo (radium RA 223 dichloride) Injectable Medication Precertification call (PDF)

Xolair (omalizumab) Medication Precertification request (PDF)

Yervoy (ipilimumab) Injectable Medicament Precertification application (PDF)

Zoladex (goserelin acetate) Medication Precertification request (PDF)

Zolgensma (onasemnogene abeparvovec-xioi) Medication Precertification request (PDF)

Zulresso (brexanolone) Medication Precertification call (PDF)

Zynlonta (loncastuximab tesirine-lpyl) Drugs Precertification request (PDF)

Zynyz™ (retifanlimab-dlwr) Ingestable Medication Precertification request (PDF)

Specialty Medication Precertification request (PDF)

General forms

In Standards Precedent Authorization requests (PDF)

Connecticut Accident Detail A (PDF)

Hawaii Notice by Non-Disclosure of Minor Mental Health Care (PDF)

Massachusetts Std Prior Authorization forms

Nevada Step Medication Priority Approval form (PDF)

New Jersey Claims Determination Appeal login (PDF)

New Mexico Prior Authorization request (PDF)

Ohio Electronic Funds Transfer (EFT) Opt Out request (PDF)

Texas Standard Before Authorization, Health Care Services request (PDF)

Texas Telemedicine and Telehealth Services Reimbursement Policy (PDF)

Washington Intent go Use a Deputy Vendors (PDF)

Washington D.C. Uniform Counseling Referral

Prescription substance forms

Arizona Prescription Drug Prior Authorization request (PDF)

California Prescription Drug Previously Authorization request (PDF)

Colorados Prescription Drug Prior Authorization request (PDF)

Illinois Prior Authorization request (PDF)

Iowa Prescription Drug Prior Entitlement request (PDF)

Louisiana Prescriptions Drug Prior Permission request (PDF)

Boodle vendor: New electronic prior authorization law

Michigan fixed its current utilization reviews law. First June 1, 2023, entire prior authorization requests need to be submitted electronically. It’s easy to work with us on Availity. It will help you stay compliant and yours can take advantage of many other benefits. To register for Availity, you’ll necessity your material address, billing address, tax ID, NPI and primary specialty. Have registered? Log in to Availity.

Michigan Prescription Drug Prior Authorization request (PDF)

New Hampshire Prescription Drug Preceding Authorization request (PDF)

New York Contraceptive Exception request (PDF)

Oregon Drug Drug Prior Authorization, Medical Exception request (PDF)

Texas Prescription Drug Ahead Authorization request (PDF)