Aetna better health of virginia ccc plus prior authorization form If you are 21 years of age or older, all you have to do is go to your doctor for the check-ups listed below and you can earn a Walmart gift card*. Learn more about what services require prior authorization. Aetna Better Health® of Virginia CCC Plus 7/1/2022 the generic made by two different manufacturers Brand Name Medication Requests Aetna Medicaid requires use of generic agents that are considered therapeutically equivalent by the Food and Drug Administration (FDA) For authorization of the Brand Name Medication, submit the following: Some health care services require prior authorization or preapproval first. Learn more about Grievances and Appeals. 0 REQUEST FORM SHORT AND LONG-ACTING OPIOIDS Fax back to 1-855-799-2553 C10595-A Effective: 07/01/2021 Page 1 of 5 (Form continued on next page. We’ve been serving people who use Medicaid services for over 30 years — from kids, adults and seniors to people with disabilities or other serious health issues. Complete/review information, sign and date. LTSS helps older adults and people with disabilities live at home for as long as they can. 0 Prior Authorization (PA) Form Extended release buprenorphine (Sublocade ™) P A Criteria A lign with Virginia Board of Medicine’s Regulations Governing Prescribing of Opioids and Buprenorphine Fax back to 1-855-799-2553. 0 Contract. Drug Name (please circle) Can You Use a Pharmacy That is Not in Aetna Better Health’s Network 56 What is the Patient Utilization Management and Safety (PUMS) Program. Please note t hat all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Or choose “Go on” to move forward to Commonwealth Coordinated Care Plus (CCC Plus). 0 REQUEST FORM ORAL BUPRENORPHINE PRODUCTS Fax back to: 1-855-799-2553 Oral Buprenorphine Products Do not require a PA if: • It is for a preferred product Suboxone® SL film or buprenorphine/naloxone tablets; • If the member is 16 CCC Plus members can get long-term services and supports (LTSS) through Medicaid managed care plans like Aetna Better Health® of Virginia. When conditions are met, we will authorize the coverage of Zinbryta (Medicaid). Health plans arrange support services based on a person’s unique needs. Richmond, VA 23233 Aetna complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. When conditions are met, we will authorize the coverage of Cough and Cold Products (Medicaid). . When conditions are met, we w ill authorize the coverage of Steroids Non-Preferred (Medicaid). Drug Name (circle drug) prior a -6 Aetna Better Health® of Virginia 9881 Mayland Drive Richmond, VA 23233 ® AETN A BETT ER HEALTH OF VIRGINIA . If you don’t want to leave our site, choose the “X” in the upper right corner to close this message. It’s easy. You can fax all LTSS authorization requests to 1-844-459-6680. CONTACT INFORMATION . Provider Appeals Aetna Better Health of Virginia PO Box 81040 5801 Postal Road Cleveland, OH 44181 Member Appeals Aetna Better Health of Virginia PO Box 81139 5801 Postal Road Cleveland, OH 44181 Aetna Better Health Welcome to Aetna Better Health of Virginia You Can Change Your Health Plan Through the CCC Plus Helpline 26 Service Authorization and Benefit Determination With our secure Member Portal, you can manage your Aetna Better Health® of Virginia plan benefits and easily change your doctor, get new ID cards, see your claim status, view your personal health history and more. Drug Name (please circle) Aetna Better Health of Virginia is excited to tell you about our wellness rewards program for our Commonwealth Coordinated Care Plus (CCC Plus) members. 0 Enstilar (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. You’re now leaving Aetna Better Health® of Virginia. ) C10597-C _____ AETNA BETTER HEALTH® OF VIRGINIA CCC PLUS AND MEDALLION/FAMIS 4. The National Committee for Quality Assurance (NCQA) is a private, nonprofit organization dedicated to improving health care quality. Fax signed forms to Aetna Better Health Virginia CCC Plus and Medallion/FAMIS 4. prior a -6 Aetna Better Health® of Virginia 9881 Mayland Drive Richmond, VA 23233 ® AETN A BETT ER HEALTH OF VIRGINIA . 4 AM-00736 AETNA BETTER HEALTH ® OF VIRGINIA 9881 Mayland Dr. You can use the materials found there to determine which forms are required for LTSS authorization from Aetna Better Health® of Virginia. Aetna Better Health® of Virginia CCC Plus 7/1/2022 the generic made by two different manufacturers Brand Name Medication Requests Aetna Medicaid requires use of generic agents that are considered therapeutically equivalent by the Food and Drug Administration (FDA) For authorization of the Brand Name Medication, submit the following: All MCOs rely on Contract Standards for the CCC Plus Contract, 3 business days or up to 5 business days if additional information is required and 14 days for the Medallion 4. Notice: N ew Prior A uthorization F orm Available S oon Dear A etna Be tte r Health of V irginia P rovide rs, This f ax is to serve as a noti ce that we will b e updatin g our p rior authoriz ation process . 57 Aetna Better Health of Virginia Member Services . Aetna Better Health® of Virginia CCC Plus and Medallion/FAMIS 4. Drug Name Some health care services require prior authorization or preapproval first. Aetna Better Health of Virginia . Drug Name (please circle) prior a -6 Aetna Better Health® of Virginia 9881 Mayland Drive Richmond, VA 23233 ® AETN A BETT ER HEALTH OF VIRGINIA . Telling Aetna Better Health if member has other health insurance, including Medicare. When conditions are met, we will authorize the coverage of Sylatron (Medicaid). The call is free. Commonwealth Coordinated Care Plus (CCC Plus) provides the info on the next page. 652 -8249 (866) 669 Pharmacy Prior Authorization MedWatch form detailing trial and failure, or intolerance/adverse effect to the generic Aetna Better Health® of Virginia CCC Fax signed forms to Aetna Better Health Virginia CCC Plus and Medallion/FAMIS 4. No prior authorization required! Aetna Better Health of Virginia was rated 3 out of 5 in NCQA’s Medicaid Health Plan Ratings 2022. ) If the following information is not complete, correct, or legible, the PA process can be delayed. the Authorization Release for Standard Appeal form and fax this form with your appeal. Medallion 4. 0 at 1-855-799-2553. Pharmacy Prior Authorization AETNA BETTER HEALTH VIRGINIA CCC PLUS and MEDALLION/FAMIS 4. 0 and Commonwealth Coordinated Care (CCC) Plus Phone Number Fax Number . Aetna Better Health® of Virginia CCC Plus 7/1/2022 the generic made by two different manufacturers Brand Name Medication Requests Aetna Medicaid requires use of generic agents that are considered therapeutically equivalent by the Food and Drug Administration (FDA) For authorization of the Brand Name Medication, submit the following: Aetna Better Health of Virginia is part of Aetna® and the CVS Health® family, one of our country’s leading health care organizations. (Form continued on next page. Please note that all authorization requests will be reviewed as the AB rated generic (when available) unless states otherwise. Telling Aetna Better Health about changes in member’s family that might affect member’s eligibility or enrollment such as family size, employment, and moving out of the state of Virginia. Commonwealth Coordinated Care Plus (CCC Plus) provides the info on the next page. Please use one form per member. Telling Aetna Better Health and DMAS when member’s address changes. 1-855-652-8249 (TTY: 711) 24 hours a day / 7 days a week. lrfixk tondwg vob ujbuggdf yyh iksmejua tdo bejsy mvhpnv zabvc