Aetna Medicare Viscosupplementation Form

Aetna Medicare Viscosupplementation Form - Aetna considers the following medically necessary Arthroscopic debridement with or without partial meniscectomy for persons presenting with mild to moderate Outerbridge classification I and II not III or IV osteoarthritis OA with knee pain plus mechanical symptoms due to loose bodies and or meniscal tears

Find the Aetna Medicare forms you need to help you get started with claims reimbursements Aetna Rx Home Delivery filing an appeal and more

Aetna Medicare Viscosupplementation Form

Aetna Medicare Viscosupplementation Form

MEDICARE FORM Viscosupplementation Injectable Medication Precertification Request . For Virginia HMO SNP: FAX: 1-833-280-5224 PHONE: 1-855-463-0933 For other lines of business: Please use other form. Note: Durolane, Euflexxa, Gelsyn-3, GenVisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz, Synvisc, Synvisc One, TriVisc are non-preferred.

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Get Forms For Your Medicare Plan Aetna Medicare

Scope of Policy This Clinical Policy Bulletin addresses viscosupplementation for commercial medical plans For Medicare criteria see Medicare Part B Criteria Precertification of viscosupplementation products are required of all Aetna participating providers and members in applicable plan designs

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Process for Medicare coverage requests appeals grievances We want to be your first stop if you have a concern about your coverage or care So if you do please call us at the number on your member ID card As an Aetna Medicare member you have the right to Ask for coverage of a medical service or prescription drug

Osteoarthritis Of The Knee Selected Treatments Aetna

Synvisc Synvisc One Hylan G F 20 Monovisc sodium hyaluronate Orthovisc high molecular weight form of hyaluronate Preferred Product Hyalgan and Gel one are the preferred viscosupplements for OA Non preferred products will not be covered Criteria for Approval Documentation of symptomatic osteoarthritis and all of the following

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Medication Request Orlando FL 32809 AetnaSpecialtyPharmacy Customer Service 1 866 782 ASRX 1 866 782 2779 Fax Order Submission 1 866 FAX ASRX 1 866 329 2779 For your convenience this medication request may be submitted via E PRESCRIBE to Aetna Specialty Pharmacy

Viscosupplementation Injectable Medications Precertification Request Form (PDF, 377 KB) Ziv-Aflibercept (Zaltrap®) Injectable Medication Precertification Request Form (PDF, 351 KB) Aetna Specialty Pharmacy offers specialized …

Aetna MEDICARE FORM Viscosupplementation

Please use Medicare Request Form Please indicate Start of treatment Start date Continuation of therapy Request Additional Series Below Precertification Requested By Phone Fax GR 68744 11 21 Continued on next page Hyaluronates Injectable Medication Precertification Request Page 2 of 2

Aetna Medicare Viscosupplementation Form

Medication Request Orlando FL 32809 AetnaSpecialtyPharmacy Customer Service 1 866 782 ASRX 1 866 782 2779 Fax Order Submission 1 866 FAX ASRX 1 866 329 2779 For your convenience this medication request may be submitted via E PRESCRIBE to Aetna Specialty Pharmacy

Find the Aetna Medicare forms you need to help you get started with claims reimbursements Aetna Rx Home Delivery filing an appeal and more

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