GR 68722 Medication Precertification Form - Aetna 2026

The document is a precertification request form for the injectable medication Benlysta® (belimumab), used primarily for treating systemic lupus erythematosus (SLE). It requires detailed patient, insurance, prescriber, and clinical information to initiate or continue therapy. The form includes sections for treatment dates, patient demographics, insurance coverage, prescriber details, administration information, product specifics, diagnosis codes, and clinical criteria necessary for approval.

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Click ‘Get Form’ to open the GR 68722 Medication Precertification Form in the editor.
Begin by filling out the 'Patient Information' section. Enter the patient's first name, last name, address, phone numbers, date of birth, allergies, current weight, and height.
Proceed to the 'Insurance Information' section. Indicate if the patient has other coverage and provide necessary details such as Aetna Member ID and Group number.
Complete the 'Prescriber Information' section by entering the prescriber's details including name, address, phone number, and specialty.
In the 'Dispensing Provider/Administration Information' section, specify where the medication will be administered and provide relevant contact information.
Fill out the 'Product Information' section with details about Benlysta (belimumab), including dose and frequency.
Complete the 'Diagnosis Information' by indicating primary and secondary ICD codes as applicable.
Finally, ensure all required clinical information is filled out in detail for precertification requests before submitting your form.

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How to get prior authorization for medication Aetna?

If you need prior authorization, talk with your primary care provider () or another health care professional. They can check on your overall health or any chronic conditions you may have. After looking over your needs, your provider will send a request to Aetna for the specific test, procedure or prescription.

What is the number for Aetna preauthorization?

For more help understanding what you need prior authorization for, call the Member Services number on your member ID card, 1-833-570-6670 (TTY: 711). Were available between 8 AM and 8 PM, 7 days a week. Are you happy with your Aetna plan?

What is precertification Aetna?

Precertification occurs before inpatient admissions and select ambulatory procedures and services. Precertification applies to: Procedures and services on the Aetna Participating Provider Precertification List. Procedures and services on the Aetna Behavioral Health Precertification List.

How to check status of prior authorization in Aetna?

To check if a service requires prior authorization, call the precertification number on the members ID card. We ask that you do not use the EDI process to make your request.