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Pharmacy prior authorization

individual forms for pharmacy prior authorization

Prior Authorization Criteria Form

9/01/2013 Prior Authorization AETNA BETTER HEALTH OF ILLINOIS Oxycontin (IL88) This

Prior Authorization Criteria Form

Prior Authorization 08/26/2015 AETNA BETTER HEALTH OF ILLINOIS FAMILY HEALTH PLAN

Prior Authorization Criteria Form

Prior Authorization 03/17/2016 AETNA BETTER HEALTH OF ILLINOIS FAMILY HEALTH PLAN

Prior Authorization Review Panel

Aetna Better Health® Pharmacy Prior Authorization Erythropoiesis – Stimulating Agents Clinical Guideline Last update: 10/2015 Page | 1 Aranesp® (darbepoetin alfa) Epogen® (epoetin alfa) Procrit® (epoetin alfa) Authorization Guidelines: For patients who meet all of the following:

Prior Authorization Criteria Form

09/25/2014 Prior Authorization AETNA BETTER HEALTH OF ILLINOIS FAMILY HEALTH PLAN

Prior Authorization Criteria Form

9/01/2013 Prior Authorization AETNA BETTER HEALTH OF ILLINOIS Vivitrol (IL88) This

Prior Authorization Criteria Form

Prior Authorization 05/02/2014 AETNA BETTER HEALTH OF ILLINOIS MEDICAID Neulasta

Prior Authorization Criteria Form

Prior Authorization 08/26/2015 AETNA BETTER HEALTH OF ILLINOIS MEDICAID Acamprosate

Prior Authorization Criteria Form

Prior Authorization 08/26/2015 AETNA BETTER HEALTH OF ILLINOIS MEDICAID Non-Calcium