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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

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

Prior Authorization Criteria Form

Prior Authorization 05/02/2014 AETNA BETTER HEALTH OF ILLINOIS MEDICAID Neulasta (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 Medicaid at 1-8

Prior Authorization Criteria Form

Prior Authorization 08/26/2015 AETNA BETTER HEALTH OF ILLINOIS MEDICAID Acamprosate (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 Medicaid at 1-8

Reference Number: C7837-A / Effective Date: 12/01/2017 1 Pharmacy Prior Authorization AETNA BETTER HEALTH ILLINOIS (MEDICAID) IPF Agents (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fa

Provider Info:

Practitioner Application Screening Form PLEASE COMPLETE ONE FORM PER PRACTITIONER IN PRACTICE Mail completed form to: Aetna Better Health, 333 West Wacke

Change In Prior Authorization Requirements-Home Health(2)

Change In Prior Authorization Requirements Aetna Better Health of IL would like to notify you that effective January 1, 2019, Aetna Better Health of IL, wil

Reference Number: C4911-A / Effective Date: 06/16/2017 1 Pharmacy Prior Authorization AETNA BETTER HEALTH ILLINOIS (MEDICAID) Aranesp (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax s

Prior Authorization Criteria Form

Prior Authorization 08/26/2015 AETNA BETTER HEALTH OF ILLINOIS MEDICAID Non-Calcium Based Phosphate Binders (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

CVS new pharmacy manager

CVS is new pharmacy manager for Aetna Better Health of Illinois