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HOTCHKIS & WILEY VALUE OPPORTUNITIES FUND CLASS A- Performance charts including intraday, historical charts and prices and keydata. Indices Commodities Currencies StocksPHONE: 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: 1-866-503-0857 . 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 treatment1-866-503-0857 . For other lines of business: Please use other form . Note: Signifor LAR is non-preferred for acromegaly. The preferred products are Sandostatin LAR and Somatuline Depot. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date . Continuation of therapy, Date of last ...The toll-free 866 reverse lookup is a feature that allows anyone receiving a call from a toll-free number beginning with 866 to find out the name of the business calling. Reverse l...Actually it helps cut down the robo calls because apparently many of the robo callers give up calling as time goes by. — Ronald K, Nov 29th, 11:21am. Block this robocall and over 8,840,584 more with Nomorobo! Stop robocalls with Nomorobo. (866) 602-0857 is a Robocall. Click here to listen.I notice that most foods I eat have normal-sounding ingredients except one -- this stuff called "carrageenan." What is carrageenan? Advertisement Lots of foods can contain some pre...Phone: 1-866-752-7021 FAX: 1-888-267-3277 For Medicare Advantage Part B: Phone: 1-866-503-0857 FAX: 1-844-268-7263 Patient First Name Patient Last Name Patient Phone Patient DOB G. CLINICAL INFORMATION (continued) - Required clinical information must be completed in its entirety for all precertification requests.GR-69025-CA (10-14) Page 1New 08/13 of 2 PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM Instructions: Please fill out all applicable sections on both pages completely and legibly . Attach any additional documentation that isFor precertification of immune globulin human intramuscular injection (IGIM) (GamaSTAN), call (866) 752-7021 (Commercial), or fax (888) 267-3277. For Statement of Medical Necessity (SMN) precertification forms, see Specialty Pharmacy Precertification. For Medicare Part B plans, call (866) 503-0857, or fax (844) 268-7263.: 1-866-503-0857 For other lines of business: Please use other form Note: Cinqair is non-preferred. The preferred products are Nucala and Xolair. G. CLINICAL INFORMATION (continued) - Required clinical information must be completed in its entirety for all precertification requests. / / Patient First Name . Patient Last Name . Patient PhoneAetna Precertification Notification Phone: 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...Phone: 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:1-866-752-7021 FAX: 1-888-267-3277 For Medicare Advantage Part B: Phone: 1-866-503-0857 FAX: 1-844-268-7263 Patient First Name . Patient Last Name . Patient Phone . Patient DOB . G. CLINICAL INFORMATION - Required clinical information must be completed in its entirety for all precertification requests.( ) Injectable Medication Precertification Request Aetna Precertification Notification 503 Sunport Lane, Orlando, FL 32809 Phone: 1-866-503-0857 FAX: 1-888-267-3277 Page 1 of 2.Reverse phone lookup for (866) 503-0857. Find full name, address, email, and photos for owner of (866) 503-0857 with Spokeo.1-866-503-0857 . For other lines of business: Please use other form. Note: Xgeva is non-preferred. The preferred products are pamidronate or zoledronic acid. Pamidronate and zoledronic acid do not require precertification. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date:Diabetic Testing Supplies Prior Authorization Request Form Ph: (866) 503-0857 Fax: (877) 269-9916 . MEMBER INFORMATION Member name . Member ID . Member Address, City, State, ZIPPhone: 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 INFORMATION First Name: Last Name: Address: City: ...1-866-503-0857 (TTY: 711) For other lines of business: Please use other form. Note: Susvimo is non-preferred. The preferred products are bevacizumab (Avastin) first followed by Byooviz or Eylea/Eylea HD. Avastin (C9257) and bevacizumab biosimilars do not require precertification for ophthalmic use. Precertification Requested By:1-866-503-0857 (All fields must be completed and legible for precertification review) Fax: 1-888-267-3277. For Medicare Advantage Part B: Please Use Medicare Request Form . Patient First Name . Patient Last Name . Patient Phone . Patient DOB . G. CLINICAL INFORMATION (continued)1-866-503-0857 . For other lines of business: Please use other form. Note: Entyvio is preferred on MA plans. On MAPD plans Entyvio is preferred for ulcerative colitis and non-preferred for Crohn's disease. (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date / /

Precertification Request for Erythropoiesis Stimulating Agents Aetna Precertification Notification 503 Sunport Lane, Orlando, FL 32809 Injectable Medication ( / / /Omontys ) Phone: 1-866-503-0857. ... Phone: 1-866-503-0857. How It Works. Open form follow the instructions. Easily sign the form with your finger Send filled & signed form or save ...Phone: 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:Exception: Requests for drugs administered by a healthcare professional that will be billed to the medical plan, call 1-866-503-0857 or fax applicable request forms to 1-888-267-3277. Policy: Note: The provision of physician samples does not guarantee coverage under the provisions of the pharmacy benefit.For Medicare Advantage Part B: Phone: 1-866-503-0857 FAX: 1-844-268-7263. G. CLINICAL INFORMATION (continued) – – Required clinical information must be completed in its entirety for all precertification requests. Yes No Was the patient prescribed the requested drug due to clinical worsening after receiving gene replacement therapy (e.g ...Phone: 1-866-503-0857 FAX: 1-888-267-3277 For Medicare Advantage Part B: Phone: 1-866-503-7021 FAX: 1-844-268-7263 G. CLINICAL INFORMATION (Continued) – Required clinical information must be completed in its entirety for all precertification requests. Please indicate which eye the treatment is being requested for?

PHONE: 1-866-503-0857 For other lines of business: please use other form. Note: Nivestym is non preferred. Zarxio is preferred. Patient First Name Patient Last Name Patient Phone Patient DOB G. CLINICAL INFORMATION (continued) - Required clinical information must be completed in its entirety for all precertification requests.1-866-752-7021 Injectable Precertification Request FAX: 1-888-267-3277 Page 2 of 4 For Medicare Advantage Part B: (All fields must be completed and legible for precertification review.) Phone: 1-866-503-0857 FAX: 1-844-268-7263 - Patient First Name . Patient Last Name . Patient Phone . Patient DOB . G. CLINICAL INFORMATION (continued)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 ...…

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