Medical Exception/
Fax this form to: 1-877-269-9916
Prior Authorization/Precertification*
Submit your request online at:
Request for Prescription Medications
Visit 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
This pre-authorization request form should be filled out by the provider. Before completing this form, please
confirm the patient’s benefits and eligibility. Benefits for services received are subject to eligibility and plan
terms and conditions that are in place at the time services are provided.
Section 1 Submission
Patient Name Patient Insurance ID Number Physician name Today’s Date
Section 2 Review
Is this request urgent? Defined as: A delay of service could seriously jeopardize the life or health of the member or the ability of the member to regain maximum function. –
Or – In the opinion of a physician with knowledge of the member’s medical condition, would subject the member to severe pain that cannot be adequately managed without
the disputed care or treatment. If this request is urgent and meets the definition as indicated above, please check this box.
Urgent Request
Date (MM/DD/YYYY):
Verify with the preauthorization list at, according to the company's procedure, or call the number on the back of the member's card.
Is this request:
New Authorization extension Providing additional information
If you already have an authorization number, list it here:
Section 3 Patient Information
Name DOB (MM/DD/YYYY) Gender
Male Female
Member ID Number Group Number Secondary Insurer Member ID Number Secondary Group Number
Height Weight
Section 4 Prescriber/Provider Information
Check one:
You are the Requesting provider Servicing provider Specialty:
Name Tax ID Number
State ZIP Code
NPI Number
DEA Number (if required)
Whom should we contact if we require more information?
Name: Phone: Fax:
Section 5 Patient’s PCP Information (If applicable)
Name Phone Fax
GR-69164 (9-16) OR Page 1 of 10
Section 6 Medication/Medical & Dispensing Information
New Therapy Renewal If Renewal, Date therapy initiated:
Route of administration: Oral/SL Topical Injection IV Other:
Administered: Doctor’s Office Dialysis Center Home Health By Patient Other:
Medication Name Dose/Strength Frequency
Length of Therapy Number of Refills Quantity
List of Previous Drugs Tried
Drug Name Dosage
Section 7 Justification
Provide the medical rationale for requested drug (include chart notes and supporting labs) and why a formulary alternative is not acceptable:
Section 8 ICD Codes
Provide all ICD-9 or ICD-10 codes and their descriptions, if available; this will help us process your request.
Codes and descriptions are:
ICD-9 ICD-10 Primary: Second: Third:
Submit the following clinical information with this form as appropriate for this request:
History & Physical
Lab/radiology/testing results
Current symptoms and functional impairments
Treatment history
information such as chart notes that support medical necessity for the request:
GR-69164 (9-16) OR Page 2 of 10
Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat
people differently based on their race, color, national origin, sex, age, or disability.
Aetna provides free aids/services to people with disabilities and to people who need language
If you need a qualified interpreter, written information in other formats, translation or other services,
call the number on your ID card.
If you believe we have failed to provide these services or otherwise discriminated based on a
protected class noted above, you can also file a grievance with the Civil Rights Coordinator by
Civil Rights Coordinator,
P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779),
1-800-648-7817, TTY: 711,
Fax: 859-425-3379 (CA HMO customers: 860-262-7705),
You can also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights Complaint Portal, available at, or
at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F,
HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).
Aetna is the brand name used for products and services provided by one or more of the Aetna group
of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and
their affiliates (Aetna).
GR-69164 (9-16) OR Page 3 of 10
GR-69164 (9-16) OR Page 4 of 10
GR-69164 (9-16) OR Page 5 of 10
GR-69164 (9-16) OR Page 6 of 10
GR-69164 (9-16) OR Page 7 of 10
GR-69164 (9-16) OR Page 8 of 10
GR-69164 (9-16) OR Page 9 of 10
GR-69164 (9-16) OR Page 10 of 10