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Integrated Care Program Hospital Name County Address City State Zip Code Phone ADVENTIST BOLINGBROOK HOSPITAL Will 500 Remington Boulevard Bolingbrook IL 60440 (630) 312-5000 ADVENTIST GLENOAKS HOSPITAL Cook 701 Winthrop Avenue Glendale Heights IL 60139 (630) 545-8000 ADVENTIST HINSDALE HOSPIT

Prior Authorization Criteria Form

Prior Authorization 03/17/2016 AETNA BETTER HEALTH OF ILLINOIS FAMILY HEALTH PLAN (MEDICAID) Remicade (IL88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to Aetna Better Health Illin

IL-2018-SB-ENG

AETNA BETTER HEALTHSM PREMIER PLAN 2018 Summary of Benefits Aetna Better HealthSM Premier Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees. www.aetnabetterhealth.com/illinois 92.06.300

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:

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

IL_formulary-september-2017

AETNA BETTER HEALTHSM PREMIER PLAN 2017 List of Covered Drugs/Formulary Aetna Better HealthSM Premier Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees. For more recent information or oth

Prior Authorization Criteria Form

09/25/2014 Prior Authorization AETNA BETTER HEALTH OF ILLINOIS FAMILY HEALTH PLAN (MEDICAID) Pulmonary Arterial Hypertension Agents (IL88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to

Prior Authorization 12/15/2016 AETNA BETTER HEALTH OF ILLINOIS FAMILY HEALTH PLAN (MEDICAID) HIV Duplicative Use (IL88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to Aetna Better H

National Coverage Determination Member Notification The Centers for Medicare & Medicaid Services (CMS) sometimes change the coverage rules that apply to an item or service covered under Medicare and through your health plan that provides Medicare benefits. When these rules are change

Prior Authorization Criteria Form

9/01/2013 Prior Authorization AETNA BETTER HEALTH OF ILLINOIS Vivitrol (IL88) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to Aetna Better Health Illinois at 1-855-684-5250. Please c