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Useful Links

I-94-037 (highmark.com) - Intravitreal Injections Policy Oct.1 2022

Medical Policies

Bevacizumab for Non-Ocular Indications - Medical Clinical Policy Bulletins _ Aetna (pdf)Download

Eylea BCBS Medical Policy (pdf)Download

UHC Commercial NDC Policy (pdf)Download

UHC NDC Requirement Policy (pdf)Download

Forms

Ophthalomolgy-Health Partners Drug Auth Form (pdf)Download

Ophthalmology-MagellanRX Drug Auth Form (pdf)Download

Ophthalmology-Avesis Authorization Form (pdf)Download

Auxiant Medical Review Request Form (pdf)Download

Ophthalmology- Medica Drug Auth Form (pdf)Download

Healthy Blue Auth Request Form (pdf)Download

BrightHealth Outpatient_Prior_Auth (pdf)Download

Ophthalmology- Amerigroup Medical Injectables Auth Request Form (pdf)Download

BCBS Arkansas Drug Predetermination Request (pdf)Download

BCBS of IL Predetermination Form (pdf)Download

BCBS of MN Drug Authorization Form (pdf)Download

BCBS of NE Timely Filing Override Request Form (pdf)Download

BCBS OF NE Reconsideration Form (pdf)Download

BCBS of NE General Authorization Form (pdf)Download

Aetna Appeal Request Form (pdf)Download

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