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:
Specialty Drug: Drug 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
    MECigna> 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
    NatlCigna> 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

    StatePayerXolair FormOther FormsXolair URLOther URLsFaxPhoneSteps
    NatlAetna> Xolair Form (5/1/13).
    > Xolair Page.
    > Forms Page.
    > Specialty Pharmacy Page.
      MECigna> 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
      NatlCigna> 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

      StatePayerKrystexxa FormOther FormsKrystexxa URLOther URLsFaxPhoneSteps
      NatlAetna> Krystexxa Request Form (10/1/15).
      > Krystexxa Page.
      > Forms Page.
      > Specialty Pharmacy Page.
      > Forms Page.
        MECigna> 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
        NatlCigna> 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

        StatePayerGrastek FormOther FormsGrastek URLOther URLsFaxPhoneSteps
        NatlAetna> Forms Page.
        > Specialty Pharmacy Page.
          MECigna> 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
          NatlCigna> 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

          StatePayerHumira FormOther FormsHumira URLOther URLsFaxPhoneSteps
          NatlAetna> Forms Page.
          > Specialty Pharmacy Page.
            MECigna> 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
            NatlCigna> 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




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            "PA Criteria/Forms by Payer/Drug"

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

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