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PHONE: 1-866-503-0857 . For other lines of business: Please use other form . Note: Trelstar is non-preferred. The preferred product is Eligard. Firmagon is also a preferred product. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date. Continuation of therapy, Date of last treatmentPhone: 1-866-752-7021 . FAX: 1-888-267-3277 . For Medicare Advantage Part B: 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 ...

Phone: 1-866-503-0857 Page 2 of 3 FAX: 1-844-268-7263 (All fields must be completed and legible for Precertification Review.) - Continued on next page G. CLINICAL INFORMATION (continued) - Required clinical information must be completed in its entirety for all precertification requests. GR-68683 (8-19) Patient First NamePolicy: Precertification Criteria; Under some plans, including plans that use an open or closed formulary, Bravelle, Cetrotide, chorionic gonadotropin, Follistim AQ, Ganirelix AC, Gonal-F/Gonal-F RFF, Menopur, novarel, Ovidrel, and pregnyl, are subject to precertification.If precertification requirements apply, Aetna considers these medications to be medically necessary for those members who ...

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