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Includes guidance for Medicare Advantage Part B versus other lines of business, notes on preferred versus non-preferred botulinum toxin products, and options for electronic prior authorization. Provides patient, insurance, prescriber, dispensing/administration, product, diagnosis, and clinical information sections used for precertification review.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/medicare-form-botulinum-toxins-injectable-medication-precertification-request/287903/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/medicare-form-botulinum-toxins-injectable-medication-precertification-request/287903.png","ImageObject",442,249,{"name":88,"@type":89},"Marry","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-24","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Which botulinum toxin products are considered preferred or non-preferred on this form?","Question",{"text":108,"@type":109},"Daxxify, Dysport, and Myobloc are noted as non-preferred. The preferred products are Botox and Xeomin.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Do Botox and Xeomin require precertification on Medicare Advantage Part B?",{"text":113,"@type":109},"The form states that Botox and Xeomin do not require precertification.",{"name":115,"@type":106,"acceptedAnswer":116},"What information is required to be completed for precertification review?",{"text":117,"@type":109},"All fields must be completed and legible for precertification review, including patient, insurance, prescriber, dispensing/administration, product, diagnosis, and required clinical documentation for initiation or continuation.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},287903,1790220133,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":79,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":73},5909892079670,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","MEDICARE FORM  \nBotulinum Toxins Injectable Medication Precertification Request Page 1 of 4  \n(All fields must be completed and legible for precertification review. )  \nFor Medicare Advantage Part B: For other lines of business:  \nPlease use commercial form.  \nNote: Daxxify, Dysport and Myobloc are non-preferred. The preferred products are Botox and Xeomin.  \nBotox and Xeomin do not require precertification.  \nWould you like to use electronic prior authorization? Consider using Availity, our electronic prior authorization portal. Learn more about Availity from the links in the table below.  \nFor phone or fax requests, refer to the table below for routing information. To determine which box to use, refer to the patient’s Aetna ID card. State specific special needs and Medicare-Medicaid Plans may be designated on the front of the ID card or in the website URL on the back of the card. If you don’t see your specific plan listed, call the number on the back of the member’s ID card to confirm routing information.  \n\n| For Aetna Medicare Advantage and Allina Health Aetna Medicare Members send request to: Phone:  1-866-503-0857 (TTY: 711)\u003Cbr>Fax:  1-844-268-7263\u003Cbr>Availity: [https://www.aetna.com/health-care-professionals/resource-center/availity.html](https://www.aetna.com/health-care-professionals/resource-center/availity.html) |\n| --- |\n| For Aetna Medicare FIDE (HMO-DSNP) Virginia Dual Eligible Special Needs Plans send request to: Phone:  1-855-463-0933\u003Cbr>Fax:  1-833-280-5224\u003Cbr>Availity: [https://www.aetnabetterhealth.com/virginia-hmosnp/providers/portal](https://www.aetnabetterhealth.com/virginia-hmosnp/providers/portal) |\n| For Aetna Medicare FIDE (HMO-DSNP) New Jersey Dual Eligible Special Needs Plans send request to: Phone:  1-844-362-0934\u003Cbr>Fax:  1-833-322-0034\u003Cbr>Availity: [https://www.aetnabetterhealth.com/new-jersey-hmosnp/providers/portal.html](https://www.aetnabetterhealth.com/new-jersey-hmosnp/providers/portal.html) |\n| For Aetna Medicare FIDE (HMO D-SNP) Illinois Dual Eligible Special Needs Plans send request to: Phone:  1-866-600-2139\u003Cbr>FAX:  1-855-320-8445\u003Cbr>Availity: [https://www.aetnabetterhealth.com/illinois/providers/portal](https://www.aetnabetterhealth.com/illinois/providers/portal) |\n| For Aetna Medicare HIDE (HMO D-SNP) Michigan Dual Eligible Special Needs Plans send request to: Phone:  1-855-676-5772\u003Cbr>Fax:  1-844-241-2495\u003Cbr>Availity: [https://www.aetnabetterhealth.com/michigan/providers/portal.html](https://www.aetnabetterhealth.com/michigan/providers/portal.html) |\n\nMEDICARE FORM  \nBotulinum Toxins Injectable Medication Precertification Request Page 2 of 4  \n(All fields must be completed and legible for precertification review. )  \nPlease indicate:  Start of treatment: Start date  / /   \n Continuation of therapy, Date of last treatment  / /   \nFor Medicare Advantage Part B: For other lines of business:  \nPlease use commercial form.  \nNote: Daxxify, Dysport and Myobloc are non-preferred. The preferred products are Botox and Xeomin. Botox and Xeomindo not require precertification.  \nPrecertification Requested By:   Phone:   Fax:    \n\n| A. PATIENT INFORMATION |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| First Name: |  |  | Last Name: |  |  |  |  |  |  | DOB: |  |\n| Address: |  |  |  |  | City: |  |  |  |  | State: | ZIP: |\n| Home Phone: |  | Work Phone: |  | Cell Phone: |  |  |  |  | Email: |  |  |\n| Patient Current Weight:   lbs or   kgs Patient Height:   inches or   cms |  |  |  |  |  |  | Allergies: |  |  |  |  |\n| B. INSURANCE INFORMATION |  |  |  |  |  |  |  |  |  |  |  |\n| Aetna Member ID \\#:   Group \\#:    Insured: |  |  | Does patient have other coverage?  Yes  No\u003Cbr>If yes, provide ID\\#:   Carrier Name:   Insured: |  |  |  |  |  |  |  |  |\n| C. PRESCRIBER INFORMATION |  |  |  |  |  |  |  |  |  |  |  |\n| First Name: |  |  | Last Name: |  |  | (Check One):  M. D.  |  |  |  |  | D.O.  N. P.  P.A. |\n| Address: |  |  |  |  |  | City","cbCaibyG1KyAGAcx","https://ap.wps.com/l/cbCaibyG1KyAGAcx","pdf",984265,"English","# Botulinum Toxins Precertification Request\n## General submission guidance\n## Routing and electronic prior authorization\n## Patient information\n## Insurance information\n## Prescriber information\n## Dispensing provider/administration information\n## Product information\n## Diagnosis information\n## Clinical information requirements","[{\"question\":\"Which botulinum toxin products are considered preferred or non-preferred on this form?\",\"answer\":\"Daxxify, Dysport, and Myobloc are noted as non-preferred. The preferred products are Botox and Xeomin.\"},{\"question\":\"Do Botox and Xeomin require precertification on Medicare Advantage Part B?\",\"answer\":\"The form states that Botox and Xeomin do not require precertification.\"},{\"question\":\"What information is required to be completed for precertification review?\",\"answer\":\"All fields must be completed and legible for precertification review, including patient, insurance, prescriber, dispensing/administration, product, diagnosis, and required clinical documentation for initiation or continuation.\"}]","MEDICARE FORM - Botulinum Toxins Injectable Medication Precertification Request | PDF",1789632865]