(belimumab) Injectable Medication Precertification Request. (belimumab) Injectable Medication Precertification Request 2026

1. Click ‘Get Form’ to open it in our editor.
2. Begin by filling out the 'Patient Information' section. Include the patient's first and last name, address, phone numbers, date of birth, allergies, weight, and height.
3. Next, complete the 'Insurance Information' section. Indicate if the patient has other coverage and provide necessary ID numbers along with Aetna Member ID and Group number.
4. Proceed to the 'Prescriber Information' section. Fill in details about the prescriber including their name, address, phone number, specialty, and relevant identification numbers.
5. In the 'Dispensing Provider/Administration Information' section, specify where the medication will be administered and provide contact information for the dispensing provider.
6. Complete the 'Product Information' section by indicating the requested product (Benlysta), dosage, and frequency.
7. Fill out the 'Diagnosis Information' with primary and secondary ICD codes as applicable.
8. Finally, ensure all clinical information is accurately completed in its entirety for precertification requests before signing at the end of the form.

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