Forms
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Appeals and disputes
- Authorization appeal
Contracted providers: Postservice appeal and claim dispute
Noncontracted providers: Appeals and disputes
Behavioral health
Postacute clinical
Prior authorization
Pharmacy
Drugs/biologics Part B prior authorization
Drugs/biologics Part B step therapy prior authorization:
- Actemra, Tofidence and Avtozma
- Avastin, Vegzelma, Avzivi and Jobevne
- Aveed, Testopel, Xyosted and Azmiro
- Durolane, Euflexxa, Gel-One, Gelsyn-3, GenVisc 850, Hyalgan, Hymovis, Sodium Hyaluronate 1%, Supartz FX, SynoJoynt, Triluron, TriVisc and Visco-3
- Eylea, Eylea HD, Lucentis, Beovu, Vabysmo, Byooviz, Cimerli and Pavblu
- Herceptin IV, Herceptin Hylecta, Herzuma, Ontruzant and Hercessi
- Intravenous Immune Globulin − Alyglo, Asceniv, Bivigam, Panzyga and Yimmugo
- Monoferric, Feraheme and Injectafer
- Myobloc
- Neupogen, Granix, Releuko and Nypozi
- PCSK9 Inhibitors and Leqvio
- Remicade
- Rituxan and Rituxan Hycela
- Sandostatin LAR
- Saphnelo
- Soliris, BKEMV
- Stelara IV
- Subcutaneous Immune Globulin − Cuvitru and Hyqvia
- Vyepti
- Ziextenzo, Nyvepria, Fylnetra, Stimufend, Rolvedon and Ryzneuta