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Coverage Redetermination | Aetna Better Health of Illinois

Prior authorization form for members who need coverage redetermination for their Part D

Coverage Determination | Aetna Better Health of Illinois

Prior authorization form for members who need coverage determination for their Part D prescription

MMP PA Criteria_Look Up Tool_05 01 2017

Prior Authorization Criteria Effective: 05/01/2017 Updated 05/2017 ACTHAR GEL Products Affected

Reference Number: C6586-A / Effective Date: 05/08/2017 1 Pharmacy Prior Authorization AETNA BETTER HEALTH ILLINOIS (MEDICAID) Tysabri for Crohn’s (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and

Reference Number: C7072-A / Effective Date: 08/19/2017 1 Pharmacy Prior Authorization

Reference Number: C6586-A / Effective Date: 05/08/2017 1 Pharmacy Prior Authorization AETNA BETTER HEALTH ILLINOIS FAMILY HEALTH PLAN (MEDICAID) Tysabri for Crohn’s (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review in

Reference Number: C7837-A / Effective Date: 12/01/2017 1 Pharmacy Prior Authorization

Reference Number: C4911-A / Effective Date: 06/16/2017 1 Pharmacy Prior Authorization

Prior Authorization 12/15/2016 AETNA BETTER HEALTH OF ILLINOIS FAMILY HEALTH PLAN

Reference Number: C6576-A/ Effective Date: 02/22/2017 1 Prior Authorization AETNA