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

'There are 10 kinds of people in this world: those who can count in binary and those who cannot.' (Mathematics Joke)



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