Collegiumcoverage.com

Search Coverages for Your State Collegium Pharmaceutical

WEBWelcome to the Collegium Coverage portal. This website contains resources and our portfolio of products’ payer coverage information for top plans in your state. Select your …

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URL: https://collegiumcoverage.com/

Belbuca Collegium Pharmaceutical Coverage

WEBBELBUCA ® (buprenorphine buccal film) is indicated for the management of severe and persistent pain that requires an extended treatment period with a daily opioid analgesic …

Category: Health Go Health

The fax number for the OptumRx Prior-Authorization Request …

WEBPlease Note: The fax number for the OptumRx Prior-Authorization Request Form on the next page has changed. The new fax number is: 1-844-403-1027

Category: Health Go Health

Elyxyb Collegium Pharmaceutical Coverage

WEBELYXYB ™ (celecoxib) oral solution is a nonsteroidal anti-inflammatory drug (NSAID) indicated for the acute treatment of migraine with or without aura in adults.. Limitations …

Category: Health Go Health

DO NOT COPY FOR FUTURE USE. FORMS ARE UPDATED …

WEB4. What is the member’s most recent score on a substance abuse/opioid dependence risk assessment tool? (Document score) ____ _____ 5.

Category: Health Go Health

REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE …

WEBFax Number: 1-855-633-7673. You may also ask us for a coverage determination by phone at 1-866-235-5660, TTY: 711, 24 hours a day, 7 days a week or through our website at …

Category: Health Go Health

Belbuca® Prior Authorization Request Form (Page 1 of 2)

WEBThis document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI).

Category: Health Go Health

Formulary Exception Form For Qualified Health Plans Only The …

WEB89-185 (12-23-15) Blue Cross and Blue Shield of Nebraska is an Independent Licensee of the Blue Cross and Blue Shield Association. The following documentation is REQUIRED …

Category: Health Go Health

MEDICARE PART D FORMULARY EXCEPTION INFORMATION

WEBPlease fax or mail the attached form to: Prime Therapeutics LLC Attn: Medicare Appeals Department TOLL FREE 2900 Ames Crossing Road Fax: 800-693-6703 Phone: 800 …

Category: Health Go Health

REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE …

WEBAttach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent). For more …

Category: Health Go Health

Provider Request for Medicare Prescription Drug Coverage …

WEBThis form may be sent to us by mail or fax: Address: Fax Number: 6450 U.S. Highway 1 1.855.328.0061 Rockledge, FL 32955 You may also ask us for a coverage …

Category: Health Go Health

Address: Fax Number: Blue Cross NC Blue Medicare HMOSM

WEBR Is the stated daily MED dose noted medically necessary? ☐YES ☐ NO Would a lower total daily MED dose be insufficient to control the enrollee’s pain?YES

Category: Medical Go Health

Request For Medicare Prescription Drug Coverage …

WEBThis form may be sent to us by mail or fax: Address: Cigna-HealthSpring Pharmacy Service Center Attn: Part D Coverage Determinations and Exceptions PO Box 20002 Nashville, …

Category: Health Go Health

Exception to Coverage Request

WEBDean Health Plan 1277 Deming Way Madison, WI 53717 1-800-279-1301 Fax: 855-668-8551 Exception to Coverage Request Allow 7 Days for Processing Complete Legibly to …

Category: Health Go Health

Request for Medicare Prescription Drug Coverage …

WEBRepresentation documentation for appeal requests made by someone other than enrollee or prescriber: Attach documentation showing the authority to represent the enrollee (a …

Category: Health Go Health

Prior Authorization Fax Form

WEBPRESCRIBER FAX FORM. Only the prescriber may complete this form. This form is for prospective, concurrent, and retrospective reviews. The following documentation is …

Category: Health Go Health

Medical Prior Authorization Form

WEBTo facilitate prompt and accurate processing, the information above must be complete and all supporting clinical documentation related to this request MUST be submitted with this …

Category: Health Go Health

Physician Fax Form

WEBOPIOIDS ER PRIOR AUTHORIZATION/MEDICAL NECESSITY DETERMINATION PRESCRIBER FAX FORM ONLY the prescriber may complete this form. This form is for …

Category: Medical Go Health

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The medical information found on the MediWells website is designed to support, not to replace the relationship between patient and physician and the medical advice they may provide.