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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.

State	Payer	Synagis Form	Other Forms	Synagis URL	Other URLs	Fax	Phone	Steps
Natl	Aetna	> Synagis Form (7/1/17). > Synagis Reorder Form (7/1/17).		> Synagis Page.	> Forms Page. > Specialty Pharmacy Page.	1-866-329-2779	1-866-503-0857
Natl	Anthem	> Synagis Request Form.			> Forms Page.
Natl	→ Anthem - Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect	> Synagis Request Form (4/1/15).
PR	Abarca Health
SC	Absolute Total Care Centene Managed Medicaid	> Synagis Form. > Synagis Form. > Synagis Form.		> Synagis Page.	> Prior Auth Page.	1-855-865-9469	1-866-433-6041 ext. 64455
CA	Access Independent Physician
SC	Advicare	> Synagis Form. > Prior Auth Form (12/12/13).			> Provider Page.	1-866-433-6041	1-866-433-6041
MO	Aetna Better Health				> Closure Announcement.			1) Effective 4/30/2017, Aetna Better Health of Missouri has closed
NE	Aetna Better Health	> Synagis Form. > Synagis Form (11/4/15).	> Appeals Form.		> Prior Auth Page. > Provider Page.
PA	Aetna Better Health	> Synagis Form. > Synagis Form. > Synagis Form (2/25/15).			> Provider Page.	1-877-309-8077	1-866-638-1232
CA	Affiliated Doctors of Orange County				> Provider Page. > Homepage.
NY	Affinity Managed Medicaid	> Prior Auth Form.	> Form.		> Forms Page. > Provider Page.
NY	→ Affinity Managed Medicaid - Child Health Plus
NY	→ Affinity Managed Medicaid - Medicaid
NY	→ Affinity Managed Medicaid - Medicare
NY	→ Affinity Managed Medicaid - Medical Benefit Drugs
CA	AHCIPA Acaria	> Synagis Form. > Synagis Form (10/1/12).			> Provider Page.
AL	Alabama Medicaid Agency	> Synagis Form. > Synagis Form. > Synagis Form. > Synagis Form. > Synagis Form (10/17/17).			> Provider Page. > Prior Auth Page. > Homepage.
CA	Alameda Alliance for Health	> Prior Auth Form.	> Provider Form. > Provider Form.		> Forms Page. > Prior Auth Page.
CA	Alamitos Independent Physicians
AK	Alaska Health and Social Services	> Synagis Form. > Synagis Form.			> Prior Auth Page. > Homepage. > Prior Auth Page.	1-888-603-7696	1-800-331-4475
OR	Allcare Health Plan		> Form.	> Synagis Page.	> Homepage.
CA	Alliance Care Management Ind
CA	Allied Healthcare Providers

State	Payer	Xolair Form	Other Forms	Xolair URL	Other URLs	Fax	Phone	Steps
Natl	Aetna	> Xolair Form (5/1/13).		> Xolair Page.	> Forms Page. > Specialty Pharmacy Page.
Natl	Anthem	> Xolair Request Form (8/18/16).			> Forms Page.
Natl	→ Anthem - Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect	> Xolair Request Form (4/1/15).
PR	Abarca Health
SC	Absolute Total Care Centene Managed Medicaid				> Prior Auth Page.
CA	Access Independent Physician
SC	Advicare				> Forms Page. > Provider Page.
MO	Aetna Better Health				> Closure Announcement.			1) Effective 4/30/2017, Aetna Better Health of Missouri has closed
NE	Aetna Better Health		> Appeals Form.		> Prior Auth Page. > Provider Page.
PA	Aetna Better Health	> Xolair Form. > Xolair Form. > Prior Auth Form (6/6/13).			> Forms Page. > Provider Page. > Forms Page.	1-877-309-8077	1-866-638-1232
CA	Affiliated Doctors of Orange County				> Provider Page. > Homepage.
NY	Affinity Managed Medicaid				> Forms Page.
NY	→ Affinity Managed Medicaid - Child Health Plus
NY	→ Affinity Managed Medicaid - Medicaid
NY	→ Affinity Managed Medicaid - Medicare
NY	→ Affinity Managed Medicaid - Medical Benefit Drugs
CA	AHCIPA Acaria				> Provider Page. > Forms Page.
AL	Alabama Medicaid Agency	> Prior Auth Form. > Prior Auth Form. > Prior Auth Form (10/19/17).	> Drug List Form.		> Pharmacy Page. > Provider Page. > Prior Auth Page. > Forms Page.
CA	Alameda Alliance for Health		> Provider Form. > Provider Form.		> Forms Page. > Prior Auth Page.
CA	Alamitos Independent Physicians
AK	Alaska Health and Social Services				> Prior Auth Page. > Homepage.
OR	Allcare Health Plan		> Form.	> Xolair Page.	> Homepage.
CA	Alliance Care Management Ind
CA	Allied Healthcare Providers

State	Payer	Krystexxa Form	Other Forms	Krystexxa URL	Other URLs	Fax	Phone	Steps
Natl	Aetna	> Krystexxa Request Form (10/1/15).		> Krystexxa Page.	> Forms Page. > Specialty Pharmacy Page. > Forms Page.
Natl	Anthem				> Forms Page.
Natl	→ Anthem - Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect
PR	Abarca Health
SC	Absolute Total Care Centene Managed Medicaid		> Form.		> Provider Page. > Homepage.
CA	Access Independent Physician
SC	Advicare				> Provider Page.
MO	Aetna Better Health				> Closure Announcement.			1) Effective 4/30/2017, Aetna Better Health of Missouri has closed
NE	Aetna Better Health		> Form.		> Prior Auth Page. > Provider Page.
PA	Aetna Better Health	> Prior Auth Form.	> Form.		> Provider Page. > Forms Page.
CA	Affiliated Doctors of Orange County				> Provider Page. > Homepage.
NY	Affinity Managed Medicaid	> Prior Auth Form.	> Form.		> Forms Page.
NY	→ Affinity Managed Medicaid - Child Health Plus	> Prior Auth Form.
NY	→ Affinity Managed Medicaid - Medicaid	> Prior Auth Form.
NY	→ Affinity Managed Medicaid - Medicare	> Prior Auth Form.
NY	→ Affinity Managed Medicaid - Medical Benefit Drugs	> Prior Auth Form.
CA	AHCIPA Acaria				> Provider Page. > Forms Page.
AL	Alabama Medicaid Agency		> Form. > Provider Form (2/11/05).		> Provider Page. > Prior Auth Page. > Pharmacy Page. > Homepage.
CA	Alameda Alliance for Health		> Provider Form. > Provider Form.		> Forms Page. > Prior Auth Page. > Forms Page.
CA	Alamitos Independent Physicians
AK	Alaska Health and Social Services				> Prior Auth Page. > Homepage.
OR	Allcare Health Plan				> Prior Auth Page. > Homepage.
CA	Alliance Care Management Ind
CA	Allied Healthcare Providers

State	Payer	Grastek Form	Other Forms	Grastek URL	Other URLs	Fax	Phone	Steps
Natl	Aetna				> Forms Page. > Specialty Pharmacy Page.
Natl	Anthem				> Forms Page.
Natl	→ Anthem - Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect
PR	Abarca Health
SC	Absolute Total Care Centene Managed Medicaid
CA	Access Independent Physician
SC	Advicare
MO	Aetna Better Health				> Closure Announcement.			1) Effective 4/30/2017, Aetna Better Health of Missouri has closed
NE	Aetna Better Health
PA	Aetna Better Health
CA	Affiliated Doctors of Orange County
NY	Affinity Managed Medicaid
NY	→ Affinity Managed Medicaid - Child Health Plus
NY	→ Affinity Managed Medicaid - Medicaid
NY	→ Affinity Managed Medicaid - Medicare
NY	→ Affinity Managed Medicaid - Medical Benefit Drugs
CA	AHCIPA Acaria
AL	Alabama Medicaid Agency
CA	Alameda Alliance for Health
CA	Alamitos Independent Physicians
AK	Alaska Health and Social Services
OR	Allcare Health Plan
CA	Alliance Care Management Ind
CA	Allied Healthcare Providers

State	Payer	Humira Form	Other Forms	Humira URL	Other URLs	Fax	Phone	Steps
Natl	Aetna				> Forms Page. > Specialty Pharmacy Page.
Natl	Anthem				> Forms Page.
Natl	→ Anthem - Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect
PR	Abarca Health
SC	Absolute Total Care Centene Managed Medicaid
CA	Access Independent Physician
SC	Advicare
MO	Aetna Better Health				> Closure Announcement.			1) Effective 4/30/2017, Aetna Better Health of Missouri has closed
NE	Aetna Better Health
PA	Aetna Better Health
CA	Affiliated Doctors of Orange County
NY	Affinity Managed Medicaid
NY	→ Affinity Managed Medicaid - Child Health Plus
NY	→ Affinity Managed Medicaid - Medicaid
NY	→ Affinity Managed Medicaid - Medicare
NY	→ Affinity Managed Medicaid - Medical Benefit Drugs
CA	AHCIPA Acaria
AL	Alabama Medicaid Agency
CA	Alameda Alliance for Health
CA	Alamitos Independent Physicians
AK	Alaska Health and Social Services
OR	Allcare Health Plan
CA	Alliance Care Management Ind
CA	Allied Healthcare Providers

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