Payer Grid: up-to-date PA criteria and forms by payer and specialty drug
Questions? Contact us at support@payergrid.com or call/text 609-937-9371
: Payer Grid

State filters: Payer/Insurance: Payer filters:
Specialty Drug: Drug filters:

Results limited to 25 payers at a time. Please select additional filters.

 
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.
StatePayerSynagis FormOther FormsSynagis URLOther URLsFaxPhoneSteps
NatlAetna> Synagis Form (7/1/17).
> Synagis Reorder Form (7/1/17).
> Synagis Page.
> Forms Page.
> Specialty Pharmacy Page.
1-866-329-27791-866-503-0857
    NatlAnthem> Synagis Request Form.
    > Forms Page.
      Natl→ Anthem - Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect> Synagis Request Form (4/1/15).
        PRAbarca Health
          SCAbsolute Total Care Centene Managed Medicaid> Synagis Form.
          > Synagis Form.
          > Synagis Form.
          > Synagis Page.
          > Prior Auth Page.
          1-855-865-94691-866-433-6041 ext. 64455
            CAAccess Independent Physician
              SCAdvicare> Synagis Form.
              > Prior Auth Form (12/12/13).
              > Provider Page.
              1-866-433-60411-866-433-6041
                MOAetna Better Health> Closure Announcement.
                • 1) Effective 4/30/2017, Aetna Better Health of Missouri has closed
                NEAetna Better Health> Synagis Form.
                > Synagis Form (11/4/15).
                > Appeals Form.
                > Prior Auth Page.
                > Provider Page.
                  PAAetna Better Health> Synagis Form.
                  > Synagis Form.
                  > Synagis Form (2/25/15).
                  > Provider Page.
                  1-877-309-80771-866-638-1232
                    CAAffiliated Doctors of Orange County> Provider Page.
                    > Homepage.
                      NYAffinity 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
                                CAAHCIPA Acaria> Synagis Form.
                                > Synagis Form (10/1/12).
                                > Provider Page.
                                  ALAlabama Medicaid Agency> Synagis Form.
                                  > Synagis Form.
                                  > Synagis Form.
                                  > Synagis Form.
                                  > Synagis Form (10/17/17).
                                  > Provider Page.
                                  > Prior Auth Page.
                                  > Homepage.
                                    CAAlameda Alliance for Health> Prior Auth Form.
                                    > Provider Form.
                                    > Provider Form.
                                    > Forms Page.
                                    > Prior Auth Page.
                                      CAAlamitos Independent Physicians
                                        AKAlaska Health and Social Services> Synagis Form.
                                        > Synagis Form.
                                        > Prior Auth Page.
                                        > Homepage.
                                        > Prior Auth Page.
                                        1-888-603-76961-800-331-4475
                                          ORAllcare Health Plan> Form.
                                          > Synagis Page.
                                          > Homepage.
                                            CAAlliance Care Management Ind
                                              CAAllied Healthcare Providers

                                                StatePayerXolair FormOther FormsXolair URLOther URLsFaxPhoneSteps
                                                NatlAetna> Xolair Form (5/1/13).
                                                > Xolair Page.
                                                > Forms Page.
                                                > Specialty Pharmacy Page.
                                                  NatlAnthem> 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).
                                                      PRAbarca Health
                                                        SCAbsolute Total Care Centene Managed Medicaid> Prior Auth Page.
                                                          CAAccess Independent Physician
                                                            SCAdvicare> Forms Page.
                                                            > Provider Page.
                                                              MOAetna Better Health> Closure Announcement.
                                                              • 1) Effective 4/30/2017, Aetna Better Health of Missouri has closed
                                                              NEAetna Better Health> Appeals Form.
                                                              > Prior Auth Page.
                                                              > Provider Page.
                                                                PAAetna Better Health> Xolair Form.
                                                                > Xolair Form.
                                                                > Prior Auth Form (6/6/13).
                                                                > Forms Page.
                                                                > Provider Page.
                                                                > Forms Page.
                                                                1-877-309-80771-866-638-1232
                                                                  CAAffiliated Doctors of Orange County> Provider Page.
                                                                  > Homepage.
                                                                    NYAffinity 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
                                                                              CAAHCIPA Acaria> Provider Page.
                                                                              > Forms Page.
                                                                                ALAlabama 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.
                                                                                  CAAlameda Alliance for Health> Provider Form.
                                                                                  > Provider Form.
                                                                                  > Forms Page.
                                                                                  > Prior Auth Page.
                                                                                    CAAlamitos Independent Physicians
                                                                                      AKAlaska Health and Social Services> Prior Auth Page.
                                                                                      > Homepage.
                                                                                        ORAllcare Health Plan> Form.
                                                                                        > Xolair Page.
                                                                                        > Homepage.
                                                                                          CAAlliance Care Management Ind
                                                                                            CAAllied Healthcare Providers

                                                                                              StatePayerKrystexxa FormOther FormsKrystexxa URLOther URLsFaxPhoneSteps
                                                                                              NatlAetna> Krystexxa Request Form (10/1/15).
                                                                                              > Krystexxa Page.
                                                                                              > Forms Page.
                                                                                              > Specialty Pharmacy Page.
                                                                                              > Forms Page.
                                                                                                NatlAnthem> Forms Page.
                                                                                                  Natl→ Anthem - Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect
                                                                                                    PRAbarca Health
                                                                                                      SCAbsolute Total Care Centene Managed Medicaid> Form.
                                                                                                      > Provider Page.
                                                                                                      > Homepage.
                                                                                                        CAAccess Independent Physician
                                                                                                          SCAdvicare> Provider Page.
                                                                                                            MOAetna Better Health> Closure Announcement.
                                                                                                            • 1) Effective 4/30/2017, Aetna Better Health of Missouri has closed
                                                                                                            NEAetna Better Health> Form.
                                                                                                            > Prior Auth Page.
                                                                                                            > Provider Page.
                                                                                                              PAAetna Better Health> Prior Auth Form.
                                                                                                              > Form.
                                                                                                              > Provider Page.
                                                                                                              > Forms Page.
                                                                                                                CAAffiliated Doctors of Orange County> Provider Page.
                                                                                                                > Homepage.
                                                                                                                  NYAffinity 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.
                                                                                                                            CAAHCIPA Acaria> Provider Page.
                                                                                                                            > Forms Page.
                                                                                                                              ALAlabama Medicaid Agency> Form.
                                                                                                                              > Provider Form (2/11/05).
                                                                                                                              > Provider Page.
                                                                                                                              > Prior Auth Page.
                                                                                                                              > Pharmacy Page.
                                                                                                                              > Homepage.
                                                                                                                                CAAlameda Alliance for Health> Provider Form.
                                                                                                                                > Provider Form.
                                                                                                                                > Forms Page.
                                                                                                                                > Prior Auth Page.
                                                                                                                                > Forms Page.
                                                                                                                                  CAAlamitos Independent Physicians
                                                                                                                                    AKAlaska Health and Social Services> Prior Auth Page.
                                                                                                                                    > Homepage.
                                                                                                                                      ORAllcare Health Plan> Prior Auth Page.
                                                                                                                                      > Homepage.
                                                                                                                                        CAAlliance Care Management Ind
                                                                                                                                          CAAllied Healthcare Providers

                                                                                                                                            StatePayerGrastek FormOther FormsGrastek URLOther URLsFaxPhoneSteps
                                                                                                                                            NatlAetna> Forms Page.
                                                                                                                                            > Specialty Pharmacy Page.
                                                                                                                                              NatlAnthem> Forms Page.
                                                                                                                                                Natl→ Anthem - Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect
                                                                                                                                                  PRAbarca Health
                                                                                                                                                    SCAbsolute Total Care Centene Managed Medicaid
                                                                                                                                                      CAAccess Independent Physician
                                                                                                                                                        SCAdvicare
                                                                                                                                                          MOAetna Better Health> Closure Announcement.
                                                                                                                                                          • 1) Effective 4/30/2017, Aetna Better Health of Missouri has closed
                                                                                                                                                          NEAetna Better Health
                                                                                                                                                            PAAetna Better Health
                                                                                                                                                              CAAffiliated Doctors of Orange County
                                                                                                                                                                NYAffinity 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
                                                                                                                                                                          CAAHCIPA Acaria
                                                                                                                                                                            ALAlabama Medicaid Agency
                                                                                                                                                                              CAAlameda Alliance for Health
                                                                                                                                                                                CAAlamitos Independent Physicians
                                                                                                                                                                                  AKAlaska Health and Social Services
                                                                                                                                                                                    ORAllcare Health Plan
                                                                                                                                                                                      CAAlliance Care Management Ind
                                                                                                                                                                                        CAAllied Healthcare Providers

                                                                                                                                                                                          StatePayerHumira FormOther FormsHumira URLOther URLsFaxPhoneSteps
                                                                                                                                                                                          NatlAetna> Forms Page.
                                                                                                                                                                                          > Specialty Pharmacy Page.
                                                                                                                                                                                            NatlAnthem> Forms Page.
                                                                                                                                                                                              Natl→ Anthem - Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect
                                                                                                                                                                                                PRAbarca Health
                                                                                                                                                                                                  SCAbsolute Total Care Centene Managed Medicaid
                                                                                                                                                                                                    CAAccess Independent Physician
                                                                                                                                                                                                      SCAdvicare
                                                                                                                                                                                                        MOAetna Better Health> Closure Announcement.
                                                                                                                                                                                                        • 1) Effective 4/30/2017, Aetna Better Health of Missouri has closed
                                                                                                                                                                                                        NEAetna Better Health
                                                                                                                                                                                                          PAAetna Better Health
                                                                                                                                                                                                            CAAffiliated Doctors of Orange County
                                                                                                                                                                                                              NYAffinity 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
                                                                                                                                                                                                                        CAAHCIPA Acaria
                                                                                                                                                                                                                          ALAlabama Medicaid Agency
                                                                                                                                                                                                                            CAAlameda Alliance for Health
                                                                                                                                                                                                                              CAAlamitos Independent Physicians
                                                                                                                                                                                                                                AKAlaska Health and Social Services
                                                                                                                                                                                                                                  ORAllcare Health Plan
                                                                                                                                                                                                                                    CAAlliance Care Management Ind
                                                                                                                                                                                                                                      CAAllied Healthcare Providers




                                                                                                                                                                                                                                        'Choose a job you love, and you will never have to work a day in your life' (Confucius)

                                                                                                                                                                                                                                        Payer Grid

                                                                                                                                                                                                                                        Payer Grid
                                                                                                                                                                                                                                        "PA Criteria/Forms by Payer/Drug"

                                                                                                                                                                                                                                        Questions? Contact us at support@payergrid.com or call/text 609-937-9371
                                                                                                                                                                                                                                         

                                                                                                                                                                                                                                        Copyright 2017 Payer Grid (Terms of Use) / Patent Pending / Valid CSS & XHTML