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TRILOGY AUTHORIZATION FORM Date: STANDARD Patient Name: EXPEDITED/URGENT DOB: Patient ID #: Referred By: Phone: Referred To: Facility: Requested Dates: From: Fax: To: Units/Visits: Diagnosis (ICD9):.

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Yes, as long as the prior authorization request is directed toward an insurer subject to Section 2212e as an insurer that delivers, issues for delivery, renews, or administers a health benefit plan in Michigan.

Aetna has contracted with eviCore healthcare, an independent specialty medical benefits management company, to administer prior authorization for Enhanced Clinical Review program.

For more information on obtaining clinical criteria or submitting a prior authorization request, refer to the Blue Cross Pharmacy Benefit Drugs page on the ereferrals.bcbsm.com website. Providers can obtain clinical criteria and forms by calling 1-800-437-3803.

Aetna partners with Novologix to offer free electronic prior authorization services for specialty drugs on Aetna's National Precertification List. You can use this service for commercial and Medicare members for all health plans.

To qualify for Medicaid in Michigan, your household income must be at or below 133% of the federal poverty level. Today's income limits for Michigan Medicaid are roughly $18,000 for an individual, $24,000 for a couple, or $36,000 for a family of four.

If your health care provider is in-network, they will start the prior authorization process. If you don't use a health care provider in your plan's network, then you are responsible for obtaining the prior authorization.

services beyond those ordinarily covered by Medicaid or needs a service that requires prior authorization (PA). In order for Medicaid to reimburse the provider in this situation, MDHHS requires that the provider obtain authorization for these services before the service is rendered.

Blue Cross Blue Shield of Michigan uses the NovoLogix® tool to manage prior authorization requests for medical benefit drugs. Note: Prior authorization requests for medical oncology and supportive care drugs are managed by Carelon Medical Benefits Management.

Your doctor must submit a request for a prior authorization for you. They must also submit an override of a drug restriction. Requests from pharmacists aren't accepted.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232