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Allergan, an AbbVie company, reserves the right to rescind, revoke, or amend this offer without notice. Patients residing in certain states may not be eligible to participate in this program.

Void if prohibited by law, taxed, or restricted. This offer is not transferable. The selling, purchasing, trading, or counterfeiting of this offer is prohibited by law. This offer has no cash value and may not be used in combination with any other discount, coupon, rebate, free trial, or similar offer for the specified prescription.

This offer is not health insurance. Offer expires December 31, By redeeming this offer, patient represents they meet the eligibility criteria above and patient understands and agrees to comply with the terms and conditions of this offer.

Pharmacist Instructions for a Patient with an Eligible Third-Party Payer: When you redeem this card, you certify that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other government programs for this prescription.

The patient's out-of-pocket expense will be reduced up to the maximum savings limit for the program. Reimbursement will be received from Change Healthcare. For any questions regarding Change Healthcare online processing, call Be careful not to touch the container tip to your eye or other surfaces, to help avoid eye injury and contamination. The most common side effect is a temporary burning sensation.

Other side effects include eye redness, discharge, watery eyes, eye pain, foreign body sensation, itching, stinging, and blurred vision. You are encouraged to report negative side effects of prescription drugs to the FDA.

Visit www. Allergan makes no guarantees that using the third-party website will result in your desired outcome. It is wholly and solely your responsibility to assess the qualifications of a potential doctor.

Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply.

The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered i. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis.

This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose. Copyright by the American Society of Addiction Medicine. Reprinted with permission. No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM.

Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept". See Aetna's External Review Program. All Rights Reserved. You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins CPBs solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc.

State Street, Chicago, Illinois Applications are available at the American Medical Association Web site, www. Go to the American Medical Association Web site. Department of Defense procurements and the limited rights restrictions of FAR CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose.

No fee schedules, basic unit, relative values or related listings are included in CPT. The responsibility for the content of this product is with Aetna, Inc.

The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept".

The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services. This information is neither an offer of coverage nor medical advice. It is only a partial, general description of plan or program benefits and does not constitute a contract. In case of a conflict between your plan documents and this information, the plan documents will govern.

Working with us. Join our network. Confirm patient eligibility Precertification lists and CPT code search. Existing health care professionals. Availity provider portal Update your data Utilization management Provider referral directory. Electronic claims. Disputes and appeals. Cost estimator and fee schedules.

Pharmacy claims. Dental claims. Pharmacy services. Update pharmacy data. Find prescription drug coverage. Clinical policy bulletins. Clinical policy bulletin overview Medical clinical policy bulletins Dental clinical policy bulletins Pharmacy clinical policy bulletins.

Medicare resources. Education, trainings and manuals. Overview Educational webinars Provider manuals Behavioral health trainings. State regulations Federal regulations. News and Insights. OfficeLink updates newsletter. Company news. Existing health care professionals Availity provider portal Update your data Utilization management Provider referral directory.

Pharmacy Pharmacy services Update pharmacy data Find prescription drug coverage. Resources Clinical policy bulletins Clinical policy bulletins Clinical policy bulletin overview Medical clinical policy bulletins Dental clinical policy bulletins Pharmacy clinical policy bulletins. Education, trainings and manuals Overview Educational webinars Provider manuals Behavioral health trainings.

Regulations State regulations Federal regulations. Forms for health care professionals. Find all the forms you need Find forms and applications for health care professionals and patients, all in one place. Read More Read Less.

Address, phone number and practice changes. Behavioral health precertification. Coordination of Benefits COB. Medicaid disputes and appeals. Medical precertification. Medicare disputes and appeals.

Medicare precertification. Medicare medical specialty drug and Part B step therapy precertification. Network application requests. Non-Medicare dispute and appeals. Oral Maxillofacial Surgery. Patient specific.

Part D forms: Please see the Medicare section of this page. Physician communications. Practice changes and provider termination. Note: This form will also update your information on our online provider directory. Specialty Pharmacy precertification commercial. State-specific forms. Legal notices Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates Aetna.

Health benefits and health insurance plans contain exclusions and limitations. You are now being directed to the AMA site Links to various non-Aetna sites are provided for your convenience only. You are now being directed to the Give an Hour site Links to various non-Aetna sites are provided for your convenience only.

You are now being directed to the CDC site Links to various non-Aetna sites are provided for your convenience only. You are now being directed to the CVS Health site.

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Aetna Inc. The information you will be accessing is provided by another organization or vendor. If you do not intend to leave our site, close this message. Each main plan type has more than one subtype. Some subtypes have five tiers of coverage. Others have four tiers, three tiers or two tiers. This search will use the five-tier subtype. It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan.

Do you want to continue? The Applied Behavior Analysis ABA Medical Necessity Guide helps determine appropriate medically necessary levels and types of care for patients in need of evaluation and treatment for behavioral health conditions.

Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any matters related to their coverage or condition with their treating provider. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply.

The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered i. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary.

Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose. Copyright by the American Society of Addiction Medicine.

Reprinted with permission. No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept".

See Aetna's External Review Program. All Rights Reserved. You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins CPBs solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. State Street, Chicago, Illinois Applications are available at the American Medical Association Web site, www. Go to the American Medical Association Web site. Department of Defense procurements and the limited rights restrictions of FAR CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose.

No fee schedules, basic unit, relative values or related listings are included in CPT. The responsibility for the content of this product is with Aetna, Inc. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement. Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept".

The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services.

This information is neither an offer of coverage nor medical advice. It is only a partial, general description of plan or program benefits and does not constitute a contract. In case of a conflict between your plan documents and this information, the plan documents will govern. Working with us. Join our network. Confirm patient eligibility Precertification lists and CPT code search. Existing health care professionals. Availity provider portal Update your data Utilization management Provider referral directory.

Electronic claims. Disputes and appeals. Cost estimator and fee schedules. Pharmacy claims. Dental claims. Pharmacy services. Update pharmacy data. Find prescription drug coverage. Clinical policy bulletins. Clinical policy bulletin overview Medical clinical policy bulletins Dental clinical policy bulletins Pharmacy clinical policy bulletins. Medicare resources. Education, trainings and manuals. Overview Educational webinars Provider manuals Behavioral health trainings.

State regulations Federal regulations. News and Insights. OfficeLink updates newsletter. Company news. Existing health care professionals Availity provider portal Update your data Utilization management Provider referral directory.

Pharmacy Pharmacy services Update pharmacy data Find prescription drug coverage. Resources Clinical policy bulletins Clinical policy bulletins Clinical policy bulletin overview Medical clinical policy bulletins Dental clinical policy bulletins Pharmacy clinical policy bulletins. Education, trainings and manuals Overview Educational webinars Provider manuals Behavioral health trainings.

Regulations State regulations Federal regulations. Electronic transaction vendors. Transactions available. Does site support browsers other than Internet Explorer IE? Change Healthcare formerly Emdeon. Experian Health formerly Passport Health.

HealthLogic Bank of America. Claim Submission, ERA. NextGen Healthcare. Office Ally. PNT Data. SSI ClaimsNet. TransUnion Healthcare formerly MedData. Waystar formerly NaviCure and ZirMed. Legal notices Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates Aetna.

Health benefits and health insurance plans contain exclusions and limitations. You are now being directed to the AMA site Links to various non-Aetna sites are provided for your convenience only.

You are now being directed to the Give an Hour site Links to various non-Aetna sites are provided for your convenience only. The migration to the new brand will happen over the next year.

Transaction Terms and Structure. About McKesson Corporation. McKesson Corporation, currently ranked 5th on the FORTUNE , is a global leader in healthcare supply chain management solutions, retail pharmacy, community oncology and specialty care, and healthcare information technology.

McKesson partners with pharmaceutical manufacturers, providers, pharmacies, governments and other organizations in healthcare to help provide the right medicines, medical products and healthcare services to the right patients at the right time, safely and cost-effectively.

United by our ICARE shared principles, our 70, employees across more than 16 countries work every day to innovate and deliver opportunities that make our customers and partners more successful — all for the better health of patients.

For more information, visit www. About CHC. CHC is a leading provider of software and analytics, network solutions and technology-enabled services that optimize communications, payments and actionable insights designed to enable smarter healthcare. Learn more at www. About Blackstone. Blackstone uncovers value by identifying great companies and enhancing their performance by providing strategic capital and outstanding management talent. Blackstone aims to grow stronger enterprises, create jobs, and enable its portfolio companies to build lasting value for its investors, their employees and all stakeholders.

It seeks to create positive economic impact and long-term value for its investors, the companies it invests in, and the communities in which it works. This is done by using extraordinary people and flexible capital to help companies solve problems. Further information is available at www. Follow Blackstone on Twitter Blackstone.

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Visit SSI. Visit TransUnion Healthcare. Visit TriZetto Provider Solutions. Visit Waystar. Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates Aetna. See all legal notices. Also of interest:. Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. The information you will be accessing is provided by another organization or vendor.

If you do not intend to leave our site, close this message. Each main plan type has more than one subtype. Some subtypes have five tiers of coverage. Others have four tiers, three tiers or two tiers. This search will use the five-tier subtype. It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan.

Do you want to continue? The Applied Behavior Analysis ABA Medical Necessity Guide helps determine appropriate medically necessary levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. Treating providers are solely responsible for medical advice and treatment of members.

Members should discuss any matters related to their coverage or condition with their treating provider. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered i.

The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary.

Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose.

Copyright by the American Society of Addiction Medicine. Reprinted with permission. No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM. Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept".

See Aetna's External Review Program. All Rights Reserved. You, your employees and agents are authorized to use CPT only as contained in Aetna Clinical Policy Bulletins CPBs solely for your own personal use in directly participating in healthcare programs administered by Aetna, Inc. State Street, Chicago, Illinois Applications are available at the American Medical Association Web site, www. Go to the American Medical Association Web site. Department of Defense procurements and the limited rights restrictions of FAR CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose.

No fee schedules, basic unit, relative values or related listings are included in CPT. The responsibility for the content of this product is with Aetna, Inc. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept". The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services.

This information is neither an offer of coverage nor medical advice. It is only a partial, general description of plan or program benefits and does not constitute a contract. In case of a conflict between your plan documents and this information, the plan documents will govern. Working with us. Join our network. Confirm patient eligibility Precertification lists and CPT code search. Existing health care professionals.

Availity provider portal Update your data Utilization management Provider referral directory. Electronic claims. Disputes and appeals. Cost estimator and fee schedules. Pharmacy claims. Dental claims. Pharmacy services.

Update pharmacy data. Find prescription drug coverage. Clinical policy bulletins. Clinical policy bulletin overview Medical clinical policy bulletins Dental clinical policy bulletins Pharmacy clinical policy bulletins. Medicare resources. Education, trainings and manuals. Overview Educational webinars Provider manuals Behavioral health trainings. State regulations Federal regulations. News and Insights. OfficeLink updates newsletter.

Company news. Existing health care professionals Availity provider portal Update your data Utilization management Provider referral directory. Pharmacy Pharmacy services Update pharmacy data Find prescription drug coverage. Resources Clinical policy bulletins Clinical policy bulletins Clinical policy bulletin overview Medical clinical policy bulletins Dental clinical policy bulletins Pharmacy clinical policy bulletins. Education, trainings and manuals Overview Educational webinars Provider manuals Behavioral health trainings.

Regulations State regulations Federal regulations. Electronic transaction vendors. Transactions available. Does site support browsers other than Internet Explorer IE? Change Healthcare formerly Emdeon. Experian Health formerly Passport Health. HealthLogic Bank of America. Claim Submission, ERA. NextGen Healthcare. Office Ally.

You can sign in to your account to see your plan documents. How to pay your premium. Learn more about how to appoint a representative. Choose someone you trust such as a spouse, family member, caregiver or friend to access or help you manage your health plan. Some medications require additional information from the prescriber for example, your primary care physician. The forms below cover requests for exceptions, prior authorizations and appeals. Complete this form to request a formulary exception, tiering exception, prior authorization or reimbursement.

Your doctor can go online and request a coverage decision for you. Prescription drug coverage determinations and appeals, drug conditions and limitations and quality assurance policies.

Medicare Advantage no prescription drug coverage appeals and grievances. UnitedHealthcare Prescription drug transition process. Get help with prescription drugs costs Extra Help.

Commitment to quality PDF Member rights and responsibilities. Medicare y Usted. Las Diferencias entre Medicare y Medicaid. To learn about what can cause automatic disenrollment from a Medicare Part C or Part D plan or to request disenrollment from your current plan to switch to Original Medicare only, please visit the Information about Disenrollment and Contract Termination page.

If you're affected by a disaster or emergency declaration by the President or a Governor, or an announcement of a public health emergency by the Secretary of Health and Human Services, there is certain additional support available to you.

If CMS hasn't provided an end date for the disaster or emergency, plans will resume normal operation 30 days after the initial declaration. Plan Information and Forms Smart decisions begin with finding the right information.