Payer Grid: up-to-date PA criteria and forms by payer and specialty drug
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State filters: Payer/Insurance: Payer filters:
Specialty Drug: Drug filters:

 
The information on this website is for general information purposes only. Verify all details with each patient's payer/policy before submitting as it is subject to change without notice as changes in insurance coverage may occur at anytime. Any reliance you place on such information is strictly at your own risk. We take no responsibility for & are not liable for any use/non-use of this information.
StatePayerSynagis FormOther FormsSynagis URLOther URLsFaxPhoneSteps
NatlAetna> Synagis Form (7/1/17).
> Synagis Reorder Form (7/1/17).
> Synagis Page.
> Forms Page.
> Specialty Pharmacy Page.
1-866-329-27791-866-503-0857

    StatePayerXolair FormOther FormsXolair URLOther URLsFaxPhoneSteps
    NatlAetna> Xolair Form (5/1/13).
    > Xolair Page.
    > Forms Page.
    > Specialty Pharmacy Page.

      StatePayerKrystexxa FormOther FormsKrystexxa URLOther URLsFaxPhoneSteps
      NatlAetna> Krystexxa Request Form (10/1/15).
      > Krystexxa Page.
      > Forms Page.
      > Specialty Pharmacy Page.
      > Forms Page.

        StatePayerGrastek FormOther FormsGrastek URLOther URLsFaxPhoneSteps
        NatlAetna> Forms Page.
        > Specialty Pharmacy Page.

          StatePayerHumira FormOther FormsHumira URLOther URLsFaxPhoneSteps
          NatlAetna> Forms Page.
          > Specialty Pharmacy Page.




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            "PA Criteria/Forms by Payer/Drug"

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