12/10/2015 Prior Authorization AETNA BETTER HEALTH OF KENTUCKY (MEDICAID) NonFormulary Medications (KY88) This fax machine is located in a secure location as required by HIPAA regulations-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient Information. Fill in the Patient Name, ID, Group No., DOB, and Phone number accurately.
3. Next, provide details for the Prescribing Physician. Include the Physician Name, Specialty, NPI Number, Fax, Phone, and Address.
4. In the Drug Name section, select from the list of drugs provided or specify another if necessary. Fill in Quantity, Frequency, Strength, Route of Administration, and Expected Length of Therapy.
5. Carefully answer each question regarding previous authorizations and treatment responses by circling 'Yes' or 'No'. Ensure to document any required information for quantity-limit exceptions.
6. Review all entered information for accuracy before signing. Confirm that you affirm the truthfulness of the information provided.
7. Finally, fax the signed form to Aetna Better Health of Kentucky at 1-855-799-2550 as instructed.

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