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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
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State filters:
Payer/Insurance:
Payer filters:
Aetna;Cigna;
Specialty Drug:
Drug filters:
Grastek;Humira;Krystexxa;Synagis;Xolair;
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
ME
Cigna
>
Synagis Request Form (5/15/17)
.
>
Synagis Criteria (8/15/17)
.
>
Provider Page
.
>
Prior Auth Drug List
.
1) Please fax completed form to (855) 840-1678
2) Urgent requests may be submitted by calling (800) 244-6224
Natl
Cigna
>
Synagis Request Form (5/15/17)
.
>
Synagis Criteria (8/15/17)
.
>
Provider Page
.
>
Prior Auth Drug List
.
1) Please fax completed form to (855) 840-1678
2) Urgent requests may be submitted by calling (800) 244-6224
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
.
ME
Cigna
>
Xolair Criteria (3/15/17)
.
>
Xolair Request Form (5/15/17)
.
>
Provider Page
.
>
Prior Auth Drug List
.
1) Please fax completed form to (855) 840-1678
2) Urgent requests may be submitted by calling (800) 244-6224
Natl
Cigna
>
Xolair Criteria (3/15/17)
.
>
Xolair Request Form (5/15/17)
.
>
Xolair Page
.
>
Provider Page
.
>
Prior Auth Drug List
.
1) Please fax completed form to (855) 840-1678
2) Urgent requests may be submitted by calling (800) 244-6224
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
.
ME
Cigna
>
Krystexxa Request Form (12/31/15)
.
>
Krystexxa Criteria (9/15/17)
.
>
Provider Page
.
>
Prior Auth Drug List
.
1) Please fax completed form to (855) 840-1678
2) Urgent requests may be submitted by calling (800) 244-6224
Natl
Cigna
>
Krystexxa Request Form (12/31/15)
.
>
Krystexxa Criteria (9/15/17)
.
>
Provider Page
.
>
Prior Auth Drug List
.
1) Please fax completed form to (855) 840-1678
2) Urgent requests may be submitted by calling (800) 244-6224
State
Payer
Grastek Form
Other Forms
Grastek URL
Other URLs
Fax
Phone
Steps
Natl
Aetna
>
Forms Page
.
>
Specialty Pharmacy Page
.
ME
Cigna
>
Provider Page
.
>
Prior Auth Drug List
.
1) Please fax completed form to (855) 840-1678
2) Urgent requests may be submitted by calling (800) 244-6224
Natl
Cigna
>
Provider Page
.
>
Prior Auth Drug List
.
1) Please fax completed form to (855) 840-1678
2) Urgent requests may be submitted by calling (800) 244-6224
State
Payer
Humira Form
Other Forms
Humira URL
Other URLs
Fax
Phone
Steps
Natl
Aetna
>
Forms Page
.
>
Specialty Pharmacy Page
.
ME
Cigna
>
Provider Page
.
>
Prior Auth Drug List
.
1) Please fax completed form to (855) 840-1678
2) Urgent requests may be submitted by calling (800) 244-6224
Natl
Cigna
>
Provider Page
.
>
Prior Auth Drug List
.
1) Please fax completed form to (855) 840-1678
2) Urgent requests may be submitted by calling (800) 244-6224
'The trouble is, you think you have time' (Buddha)
Payer Grid
"PA Criteria/Forms by Payer/Drug"
Questions? Contact us at
support@payergrid.com
or call/text 609-937-9371
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Payer Grid
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