Phone: 1-866-503-0857. FAX: 1-844-268-7263 (All fields must be completed and legible for Precertification Review.) Please indicate: Start of treatment, start date: / / Continuation of therapy, date of last treatment: / / Precertification Requested By: Phone: Fax: A. PATIENT INFORMATION First Name: Last Name: Address: City: ...PHONE: 1-866-503-0857 (TTY: 711) For other lines of business: Please use other form. Note: Lupron Depot is non-preferred. The preferred product Page 1 of 3 is Eligard. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date / / Continuation of therapy, Date of last treatment / /

Exception: Requests for drugs administered by a healthcare professional that will be billed to the medical plan, call 1-866-503-0857 or fax applicable request forms to 1-888-267-3277. For Oral Corticosteroid Clinical policy click here . Policy:This call could be a scam. There are several versions of these that I have heard of: Generally there is a representation that the person calling is an official or owed money and that there is a court case that can be dealt with immediately with a credit card payment. These can be ignored. If there is another call demand to know the full name of the person; the return telephone number and ...1-866-503-0857 FAX: 1-844-268-7263 . For other lines of business: Please use other form. Note: Ocrevus is non-preferred for relapsing forms of multiple sclerosis for MAPD plans. The preferred product is Kesimpta. GR-69329-3 (1-23) Page 1 of 2 (All fields must be completed and return all pages for precertification review.) Please indicate:Policy: Precertification Criteria; Under some plans, including plans that use an open or closed formulary, Intravenous Immunoglobulins (IVIG) and Adagen are subject to Precertification. If Precertification requirements apply Aetna considers these medications to be medically necessary for those members who meet the following precertification criteria: (see also Appendix A)(866) 503-0857 Anthem/Blue Cross Blue Shield Phone numbers vary by location; it is best to call the number on the back of the insurance card. Cigna Phone: (800) 244-6224 Fax number for individual drug forms (forms available for download on website): (855) 840-1678 Fax number for the following states: Arkansas,

1-866-752-7021 Medication Precertification Request FAX: 1-888-267-3277 Page 2 of 2 For Medicare Advantage Part B: (All fields must be completed and legible for Precertification Review.) Phone: 1-866-503-0857 FAX: 1-844-268-7263 Patient First Name1-866-752-7021 Medication Precertification Request FAX: 1-888-267-3277 Page 2 of 2 For Medicare Advantage Part B: (All fields must be completed and legible for precertification review.) Phone: 1-866-503-0857 FAX: 1-844-268-7263 G. CLINICAL INFORMATION (continued)

call 1-866-503-0857 or fax the related Medication Request Form to 1-888-267-3277. Forms are available on our secure provider website. Newly approved drugs administered orally, by injection or infusion may be subject to precertification review. ***The removal of a service from the precertification list does not mean that thecall 1-866-503-0857 or fax the related Medication Request Form to 1-888-267-3277. Forms are available on our secure provider website. Newly approved drugs administered orally, by injection or infusion may be subject to precertification review. ***The removal of a service from the precertification list does not mean that the

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