Aetna Forms for Prior Authorization

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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:

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: ………………………………

 

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:

 

Are additional risk factors (e.g., GI risk, cardiovascular risk, age) present? If so, please provide risk factors: …………………………………………………………………………………………………………………………….

 

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.)

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