For those who are looking for Aetna forms for health care professionals, there is a page on the official website of Aetna where you will be able to find them, as well as applications, all in one place. Here is the link that will take you to the page to find all of them on this page. There are a lot of forms that you will be able to find on the page. Some of them are related to prior authorization. If you need Aetna forms for prior authorization, below are two of them that you can check out:
Form 1: Aetna Medical Exception/Prior Authorization/Precertification Request for Prescription Medications
Medical Exception/Prior Fax this form to: 1-877-269-9916
Authorization/Precertification* OR
Request for Prescription Sumbit your request online at:
Medications www.availity.com
Visit www.aetna.com/formulary to access
our Pharmacy Clinical Policy Bulletins.
For FASTEST service, call 1-855-240-0535, Monday-Friday, 8 a.m. to 6 p.m. Central Time
Patient Information | Prescriber Information | ||
Patient Name | Today’s Date | ||
Patient Insurance ID Number | Physician Name | ||
Patient Address, City, State, ZIP | Physician Address | ||
Home Telephone | M.D. Office Telephone Number | ||
Gender
Male Female |
Patient Date of Birth | M.D. Office Fax Number | |
Diagnosis and Medical Information | |||
Medication | Strength | Frequency | |
Expected Length of Therapy | Quality | Day Supply | If this is a continuation of therapy, how long has the patient been on the medication? |
Is this medication being used to treat a chronic or long-term condition for which this prescription may be necessary for the life of the patient? Yes No | |||
PLEASE CHECK ALL BOXES THAT APPLY:
Do you want a drug specific prior authorization criteria form faxed to your office? Yes No (If yes, no further questions are required). What condition is the drug being prescribed for? ICD code……………………………………………………………… Diagnosis………………………………………………………………………………………………………………………………… Does the patient have a diagnosis of cancer? Yes No STEP THERAPY may be required. Please list all medications the patient has tried specific to the diagnosis and specify below: Therapeutic failure, including length of therapy for each drug: ………………………………… Drugs (s) contraindicated: ………………………………………………………………………………………… Adverse even (e.g., toxicity, allergy) for each drug: …………………………………………………… Is the request for a patient with one or more chronic conditions (e.g., psychiatric condition, diabetes) who is stable on the current drug(s) and who might be at high risk for a significant adverse event with a medication change? If so, specify anticipated significant adverse event: |
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Has the condition been confirmed by diagnostic testing? If so, please provide diagnostic test and date: | |||
Please provide any patient lab testing values for the members diagnosis: ………………………………
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Does the patient have a clinical condition for which others alternatives are not recommended based on published guidelines or clinical literature? If so, please provide documentation:
Does the patient require a specific dosage (e.g., suspension, solution, injection)? If so, please provide dosage form:
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Are additional risk factors (e.g., GI risk, cardiovascular risk, age) present? If so, please provide risk factors: …………………………………………………………………………………………………………………………….
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Others: Please provide additional relevant information: ………………………………………………………… | |||
REQUIRED CLINICAL INFORMATION: PLEASE PROVIDE ALL RELEVANT CLINICAL DOCUMENTTAION TO SUPPOORT USE OF THIS MEDICATION. PLEASE COMPLETE CORRESPONDING SECTION ON BACK PAGE FOR THE SPECIFIC DRUG/CLASS LISTED BELOW.
Antiemetic (5-HT3) Agents/Erectile Dysfunction Agents/Stimulants/Provigil, Nuvigil/Testosterones **FOR ANY DRUG/CLASS NOT LISTED ON THE BACK PAGE, PLEASE ATTACH ADDITIONAL INFORMATION, BUT CANNOT EXCEED TWO PAGES** PRESCRIPTION BENEFIT PLAN MAY REQUEST ADDITIONAL INFORMATION OR CLARIFICATION, IF NEEDED, TO EVALUATE REQUESTS |
Urgent Request: I certify that applying a standard review timeframe might seriously jeopardize the life or health of the patient. | |
I attest that the medication requested is medically necessary for this patient. I further attest that the information provided is accurate and true, and that documentation supporting this information is available for review if requested by the health plan sponsor, or, if applicable, a state or federal regulatory agency. I understand that any person who knowingly makes or causes to be made a false record or statement that is material to a claim ultimately paid by the United States government or any state government may be subject to civil penalties and treble damages under both the federal and state False Claims Acts. See, e.g., 31 U.S.C. §§ 3729-3733 | |
Prescriber Signature | Date |
Confidentiality Notice: The documents accompanying this transmission contain confidential health information that is legally privileged. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution of these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately (via return FAX) and arrange for the return or destruction of these documents. | |
PLEASE COMPLETE CORRESPONDING SECTION FOR THESE SPECIFIC DRUGS/CLASSES LISTED BELWO AND CIRCLE THE APPROPRIATE ANSWER OR SUPPLY RESPONSE | |
ERECTILE DYSFUNCTION: CIALIS, LEVITRA, VIAGRA, ALPROSTADIL:
Does the patient require nitrate therapy on a regular OR on an intermittent basis, or is the patient currently taking another ED medication? Yes No If a diagnosis of erectile dysfunction, is it due to neurogenic etiology, vasculogenic etiology, psychogenic etiology or mixed etiology? Yes No Is it being used for symptomatic Benign Prostatic Hyperplasia (BPH)? Yes No ANTIEMETIC (5-HT3) AGENTS: Is the patient receiving moderate to highly emetogenic chemotherapy? Monthly frequency Is the patient receiving radiation therapy? Monthly frequency Yes No If the patient has a diagnosis of Hyperemesis Gravidarum, has the patient experienced an inadequate treatment response to two of the following medications? Yes No Vitamin B6, doxylamine, promethazine (Phenergan), trimethobenzamide (Tigan) or metoclopramide (Reglan)? Yes No TOPICAL TESTOSTERONES REPLACEMENT (lab requirements): For testosterone replacement therapy, has the member been confirmed by one of the following Yes No 1. Two total fasting serum testosterone levels (below the testing laboratory’s reference range of below 300ng/dl if reference ranges are not available) which were drawn in the morning between 7:00 a.m. and 10:00 a.m. on two different days, OR 2. 2. Persons with low normal total testosterone levels (above 300 ng/dL but below 400 ng/dL, two low free or bioavailable fasting serum testosterone levels (below the testing laboratory’s reference range or less than 225 picomoles per liter (pmol/L) (6 ng/dL) if reference ranges are not available) which were drawn in the morning between 7:00 a.m. and 10:00 a.m. on two different days PROVIGIL/NUVIGIL: If the patient has a diagnosis of Obstructive Sleep Apnea, is the patient currently using a continuous positive airway pressure (CPAP) machine or another device? Yes No ADHD STIMULANT AND NON-STIMULANTS: Is this a renewal of existing therapy? Yes No |
Form 2: Aetna Better Health prior authorization request form
AETNA BETTER HEALTH
Prior authorization request form
SERVICE REQUESTED: Please PRINT LEGIBLY or TYPE. Please do not submit this form without supporting clinical.
DME (check one if applicable): Rental Purchase
MEMBER INFORMATION | |
Name: | PCP Name: |
DOB: | Other insurance?: |
Member ID#: | Policy Number: |
Gender (circle one): M or F | Policy Holder: |
PROVIDER INFORMATION | |
Ordering Physician/Nurse Practitioner: | Servicing Provider/Facility/Physician: |
Name: | Name: |
Address: | Address: |
Tel: | Tel: |
Fax: | Fax: |
Contact Person: | Specialty: |
NPI: | NPI: |
REQUIRED CLINICAL INFORMATION | |
Diagnoses (list CODES & description): | |
1. | 2. |
3. | 4. |
Procedure/service requested (list all CPT/HCPCS CODES & descriptions required): | |
1. | 5. |
2. | 6. |
3. | 7. |
Date(s) of service: | # of units/visits: |
For Home Health (shift one) ONLY: | |
Number of hours per day: | Number of days per week: |
(Telephone) 1-866-638-1232 (Fax) 1-877-363-8120
REQUIRED DOCUMENTATION |
Please attach supporting clinical information (e.g., Plan of Care, medical records, lab reports, letter of medical necessity, progress notes, etc). Requests received without supporting clinical notes and required codes WILL NOT be reviewed.
IF THIS IS A REQUEST FOR THERAPY, PLEASE USE A SEPARATE FORM FOR EACH SERVICE! (e.g., one form for PT with all codes and clinical, one form for OT with all codes and clinical etc.) |