GR-68988 (11-23) Page 1 of 6
Medical Exception/Prior
Authorization/Precertification*
Request for Prescription
Medications
Non-Specialty drug Prior Authorization
Requests Fax: 1-877-269-9916
Specialty drug Prior Authorization Requests
Fax: 1-888-267-3277
OR, Submit your request online at:
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
Patient Name
Patient Insurance ID Number
Patient Address, City, State, ZIP
Home Telephone
Gender
Male Female
Patient Date of Birth
Prescriber Information
Today’s Date
Physician Name
Physician Address
M.D. Office Telephone Number
M.D. Office Fax Number
Diagnosis and Medical Information
Medication Strength Frequency
Expected Length of Therapy Quantity 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 medication 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 pertinent lab testing values for the members diagnosis :
Does the patient have a clinical condition for which other alternatives are not recommended based on published guidelines or clinical literature?
If so, please provide documentation:
Does the patient require a specific dosage form (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:
Other: Please provide additional relevant information:
REQUIRED CLINICAL INFORMATION: PLEASE PROVIDE ALL RELEVANT CLINICAL DOCUMENTATION TO SUPPORT 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
GR-68988 (11-23) Page 2 of 6
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 BELOW 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
Yes No
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?
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
1. tw
o total fasting serum testosterone levels (below the testing laboratory's reference range or below 300ng/dl if reference
ranges are not available) which were drawn in the morning betw
een 7:00 a.m. and 10:00 a.m. on two different days, OR
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
Yes No
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 STIMULANTS AND NON-STIMULANTS:
Is this a renewal of existing therapy?
Yes No
GR-68988 (11-23) Page 3 of 6
Aetna complies with applicable Federal civil rights laws and does not unlawfully discriminate,
exclude or treat people differently based on their race, color, national origin, sex, age, or disability.
We provide free aids/services to people with disabilities and to people who need
language assistance.
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
contacting:
Civil Rights Coordinator,
P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 2
4030 Fresno, CA 93779),
1-800-648-7817, TTY: 711,
Fax: 859-425-3379 (CA HMO customers: 860-262-7705), [email protected].
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 https://ocrportal.hhs.gov/ocr/portal/lobby.jsf,
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.
GR-68988 (11-23) Page 4 of 6
TTY:711
English To access language services at no cost to you, call the number on your ID card.
Albanian
Për shërbime përkthimi falas për ju, telefononi në numrin që gjendet në kartën tuaj të
identitetit.
Amharic
የቋንቋ አገልግሎቶችን ያለክ
ፍያ ለማግኘት፣ በመታወቂያዎት ላይ ያለውን ቁጥር ይደውሉ
Arabic .ﻚﻛﺍ ﺮ
ﺘﺷﺍ ﺔﻗﺎﻄﺑ ﻰﻠﻋ
ﺩﻮﺟﻮﻤﻟﺍ ﻢﻗﺮﻟﺍ ﻰﻠﻋ ﻝﺎﺼﺗﻻﺍ ءﺎﺟﺮﻟﺍ ،ﺔﻔﻠﻜﺗ ﻱﺃ ﻥﻭﺩ ﺔﻳﻮﻐﻠﻟﺍ ﺕﺎﻣﺪﺨﻟﺍ ﻰﻠﻋ ﻝﻮﺼﺤﻠﻟ
Armenian
Ձեր նախընտրած լեզվով ավվճար խորհրդատվություն ստանալու համար
զանգահարեք ձեր բժշկական
ապահովագրության քարտի վրա նշված
հէրախոսահամարով
Bantu-Kirundi
Kugira uronke serivisi z'indimi ata kiguzi, hamagara inomero iri ku karangamuntu kawe
Bengali
Burmese
Catalan
Per accedir a serveis lingüístics sense cap cost per a vostè, telefoni al número indicat a la
seva targeta d’identificació.
Cebuano
Aron maakses ang mga serbisyo sa lengguwahe nga wala kay bayran, tawag
i ang numero
nga anaa sa imong kard sa ID.
Chamorro
Para un hago' i setbision lengguåhi ni dibåtde para hågu, ågang i numiru gi iyo-mu kard
aidentifikasion.
Cherokee
ᏩᎩᏍᏗ ᎦᏬᏂᎯᏍᏗ
ᎢᏅᎾᏓᏛᏁᏗ Ꮭ ᎪᎱᏍᏗ ᏗᏣᎬᏩᎳᏁᏗ ᏱᎩ, ᏫᎨᎯᏏᎳᏛᏏ ᎾᏍᎩ ᏗᏎᏍᏗ
ᏥᏕᎪᏪᎵ ᎤᎾᎢ ID ᏆᏂᏲᏍᏗ ᏣᏤᎵᎢ
.
Chinese
Traditional
如欲使用免費語言服務，請撥打您健康保險
卡上所列的電話號碼
Choctaw
Anumpa tos
holi i toksvli ya peh pilla ho ish i payahinla kvt chi holisso kallo iskitini
holhtena tak
anli ma i payah
Chuukese
Ren omw kopwe angei aninisin eman chon awewei (es
e kamé), kopwe kééri ewe nampa
mei mak won noum ena katen ID
Cushitic-
Oromo
Tajaajiiloota afaanii gatii bilisaa ati argaachuuf,lakkoofsa fuula
waraaqaa eenyummaa (ID)
kee irraa jiruun bilbili.
Dutch
Voor gratis taaldiensten, bel het nummer op uw ziekteverzekeringskaart.
French
Pour accéder gratuitement aux services linguistiques, veuillez composer le numéro
indiqué sur votre carte d'assurance santé.
French Creole
(Haitian)
Pou ou jwen
n sèvis gratis
nan lang ou,
rele nimewo
telefòn ki sou kat idantifikasyon
asirans sante ou.
German
Um auf den für Sie kostenlosen Sprachservice auf Deutsch zuzugreifen, rufen Sie die
Nummer auf Ihrer ID-Karte an.
Greek
Για πρόσβαση στις υπηρεσίες γλώσσας χωρίς χρέωση, καλέστε
τον αριθμό στην κάρτα
ασφάλισής σας.
Gujarati
Hawaiian
No ka walaʻau ʻana me ka lawelawe ʻōlelo e kahea aku i ka helu kelepona ma kāu kāleka
ID. Kāki ʻole ʻ
ia kēia kōkua nei.
GR-68988 (11-23) Page 5 of 6
Hindi
Hmong
Yuav kom tau kev pab txhais lus tsis muaj nqi them rau koj, hu tus naj npawb ntawm koj
daim npav ID.
Igbo
Inweta enyemaka asụsụ na akwughi ụgwọ obụla, kpọọ nọmba nọ na kaadi njirimara gị
Ilocano
Tapno maakses dagiti serbisio ti pagsasao nga awanan ti bayadna, awagan ti numero nga
adda ayan ti ID kardmo.
Indonesian
Untuk mengakses layanan bahasa tanpa dikenakan biaya, silakan hubungi nomor telepon
di kartu asuransi Anda.
Italian
Per accedere ai servizi linguistici senza alcun costo per lei, chiami il numero sulla tessera
identificativa.
Japanese 無料の言語サービスは、IDカードにある番号にお電話ください。
Karen
Korean
무료 다국어 서비스를 이용하려면 보험 ID 카드에 수록된 번호로 전화해 주십시오.
Kru-Bassa
I nyuu kosna mahola ni language services ngui nsaa wogui wo, sebel i nsinga i ye ntilga i
kat yong matibla
Kurdish
Lao
Marathi
Marshallese
Micronesian-
Ponapean
Pwehn alehdi sawas en lokaia kan ni sohte pweipwei, koahlih nempe nan amhw
doaropwe en ID.
Mon-Khmer,
Cambodian
Navajo
Nepali
̈
Nilotic-Dinka
Të kɔɔr yïn ran de wɛ ɛ
r de thokic ke cïn wëu kɔr ke
ek tënɔŋ yïn. Ke yïn cɔl ran ye kɔc
kuɔny në namba de abac tɔ
në ID kard duɔ
n de tïït de nyin de panakim kɔ
u.
Norwegian
For tilgang til kostnadsfri språktjenester, ring nummeret på ID-kortet ditt.
Pennsylvanian-
Dutch
Um Schprooch Services zu griege mitaus Koscht, ruff die Nummer uff dei ID Kaart.
Persian Farsi
Polish
Aby uzyskać dostęp do bezpłatnych usług językowych, należy zadzwonić pod numer
podany na karcie identyfikacyjnej.
Portuguese
Para aceder aos serviços linguísticos gratuitamente, ligue para o número indicado no seu
cartão de id
e
ntificação.
̈
̈ ̈ ̈
Page 6 of 6
Punjabi
Romanian
Pentru a accesa gratuit serviciile de limbă, apelați numărul de pe cardul de membru.
Russian
Для того чтобы бесплатно получить помощь переводчика, позвоните по телефону,
приведенному на ваше
й идентификационной карте.
Samoan
Mō le mauaina o 'au'aunaga tau gagana e aunoa ma se totogi, vala'au le numera i luga o
lau pepa ID.
Serbo-Croatian
Za bespl
atne
prevodil
ačke usluge pozovite broj naved
en na Vašoj identifikacionoj kartici.
Spanish
Para acceder a los servicios lingüísticos sin costo alguno, llame al número que figura en
su tarjeta de identificación.
Sudanic
Fulfulde
He
eɓa a naasta nder ekkitol jaangirde woldeji walla yoɓugo, ewnu lamba je ɗon windi ha
do ɗerowol maaɗa.
Swahili
Kupata huduma za lugha bila malipo kwako, piga nambari iliyo kwenye kadi yako ya
kitambulisho.
Syriac-
Assyrian
Tagalog
Upang ma-access ang mga serbisyo sa wika nang walang bayad, tawagan ang numero sa
iyong ID card.
Telugu
Thai
Tongan
Kapau ‘oku ke fiema’u ta’etōtōngi ‘a e ngaahi sēvesi kotoa pē he ngaahi lea kotoa,
telefoni ki he fika ‘oku hā atu ‘i ho’o ID kaati.
Turkish
Dil hizmetler
ine ücretsiz olarak erişmek için kimlik kartınızdaki numarayı arayın.
Ukrainian
Щоб безкоштовнj отримати мовні послуги, задзвоніть за номером, вказаним на
вашій ідентифікайній картці.
Urdu
Vietnamese
Để sử dụng các dịch vụ ngôn ngữ miễn phí, vui lòng gọi số điện thoại ghi trên thẻ ID của
quý vị.
Yiddish
.לטראק ID רעייא
ףיוא רעמונ םעד טפור ,לאצפא ןופ יירפ סעסיוורעס ךארפש ןעמוקאב וצ
Yoruba
GR-68988 (11-23)
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