Aetna medication precertification request form 2026

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  1. Click ‘Get Form’ to open the Aetna Medication Precertification Request Form in our editor.
  2. Begin by filling out the 'Start of treatment' and 'Continuation of therapy' sections, ensuring you provide accurate dates.
  3. In Section A, enter the patient's information including their first name, last name, address, and contact details. Make sure all fields are legible.
  4. Proceed to Section B for insurance information. Indicate if the patient has other coverage and provide necessary ID numbers.
  5. Complete Section C with prescriber information. Include the prescriber's name, specialty, and contact details.
  6. In Section D, specify the dispensing provider or pharmacy details along with administration information.
  7. Fill out Section E with product information including the requested medication dose and directions for use.
  8. Provide diagnosis information in Section F by entering primary and any additional ICD codes as applicable.
  9. Complete Section G by selecting the appropriate diagnosis and indicating if there has been a positive clinical response for continuation requests.
  10. Finally, sign and date the form in Section H to acknowledge completion before submitting it for review.

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To receive coverage for a medication requiring prior authorization, you can: Ask your healthcare provider to submit the request. Your healthcare provider can submit the request online, by fax or phone by accessing our providers prior authorization information. Submit your own prior authorization request.
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.
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.

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