Xolair Prior Authorization Form

Xolair Prior Authorization Form - Xolair omalizumab Injectable Aetna Precertification Notification Phone 1 866 752 7021 Medication Precertification Request FAX 1 888 267 3277 Page 2 of 2 For Medicare Advantage Part B Phone 1 866 503 0857 All fields must be completed and legible for precertification review FAX 1 844 268 7263 Patient First Name

Xolair CCRD Prior Authorization Form Fax completed form to 855 840 1678 If this is an URGENT request please call 800 882 4462 800 88 CIGNA Xolair omalizumab asthma Is this medication being prescribed by or in consultation with an allergist immunologist or pulmonologist Yes No

Xolair Prior Authorization Form

Xolair Prior Authorization Form

Initial Authorization Xolair will be approved based on one of the following criteria: All of the following: Patient has been established on therapy with Xolair for moderate to severe persistent asthma under an active UnitedHealthcare prior authorization -AND-

Download Recertification Reminder Program Enrollment Form Use this form to enroll your practice in the XOLAIR Recertification Reminder Program for patient prior authorization reminder notifications Download

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Initial Authorization Xolair will be approved based on one of the following criteria All of the following Patient has been established on therapy with Xolair for moderate to severe persistent asthma under an active UnitedHealthcare prior authorization AND Documentation of positive clinical response to Xolair therapy AND

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Request for Prior Authorization Omalizumab Xolair CONTAINS CONFIDENTIAL PATIENT INFORMATION Complete form in its entirety and fax to the Prior Authorization of Benefits Center at 844 512 9004 If you have questions or need assistance call the Provider Help Desk at 800 454 3730 1 Patient information 2 Physician information

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Prior Authorization XOLAIR Access Solutions can help you identify if a prior authorization PA is necessary and offer resources as you request it for your patient submit the completed Prescriber Service Form and the Respiratory Patient Consent Form to XOLAIR Access Solutions Eligible patients experiencing a delay in establishing health

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Is prior authorization in place Yes No Auth Primary Insurance Secondary Insurance Pharmacy Benefit Insurance name Subscriber name if not patient Subscriber Policy ID Group Insurance phone Step 3 Diagnosis and Clinical Information Complete to the highest level of specificity for diagnosis codes Allergic Asthma

Xolair® (omalizumab) Injectable Aetna Precertification Notification. Phone: 1-866-752-7021. Medication Precertification Request. FAX: 1-888-267-3277. Page 1 of 3 For Medicare Advantage Part B: (All fields must be completed and legible for precertification review.) Please Use Medicare Request Form. Please indicate: Start of treatment: Start date.

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Prior Authorization Request Form Fax Back To 866 940 7328 Phone 800 310 6826 Specialty Medication Prior Authorization Cover Sheet This cover sheet should be submitted along with a Pharmacy Prior Authorization Medication Fax Request Form Please refer to uhcprovider for medication fax request forms Patient Information

Xolair Prior Authorization Form

Is prior authorization in place Yes No Auth Primary Insurance Secondary Insurance Pharmacy Benefit Insurance name Subscriber name if not patient Subscriber Policy ID Group Insurance phone Step 3 Diagnosis and Clinical Information Complete to the highest level of specificity for diagnosis codes Allergic Asthma

Xolair CCRD Prior Authorization Form Fax completed form to 855 840 1678 If this is an URGENT request please call 800 882 4462 800 88 CIGNA Xolair omalizumab asthma Is this medication being prescribed by or in consultation with an allergist immunologist or pulmonologist Yes No

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