18667822779 2026

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4.7 out of 5

41 votes

The document is a Patient Profile Form for Aetna Specialty Pharmacy, detailing the steps for submitting new prescriptions and refills. It includes sections for patient information, insurance details, physician information, and payment methods. The form emphasizes the importance of providing accurate information and outlines the process for medication delivery and payment confirmation.

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Click ‘Get Form’ to open the Patient Profile Form in the editor.
Begin with SECTION A - PATIENT INFORMATION. Fill in your first name, last name, address, and contact numbers. Indicate if you have had a transplant and provide relevant details.
Move to SECTION B - INSURANCE AND COPAY ASSISTANCE INFORMATION. Enter your primary and secondary insurance details, including carrier names and member IDs.
Proceed to SECTION C - PHYSICIAN INFORMATION. Input your physician's first and last name, address, and contact information.
Complete SECTION D - PAYMENT INFORMATION by selecting your method of payment. Ensure all required fields are filled accurately for smooth processing.
Review all sections for accuracy before submitting the form along with your prescriptions.

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Versions	Form popularity	Fillable & printable
2017	4.7 Satisfied (41 Votes)
2009	4.9 Satisfied (31 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Are Aetna and CVS Caremark the same?

CVS Caremark Mail Service Pharmacy, CVS Specialty and Aetna are part of the CVS Health family of companies. Health benefits and health insurance plans contain exclusions and limitations.

Who is Aetnas specialty pharmacy?

Aetna Specialty Pharmacy refers to Aetna Specialty Pharmacy LLC, a subsidiary of Aetna Inc., which is a licensed pharmacy that operates through specialty pharmacy prescription fulfillment. Burmans Apothecary For members in Connecticut, Delaware, Indiana, New Jersey, Pennsylvania and South Carolina.

Is Optum Specialty Pharmacy the same as OptumRx?

Optum Specialty Pharmacy is affiliated with Optum Rx, a pharmacy benefits manager. You may not be required to use Optum Specialty Pharmacy for your specialty medication.

What is another name for CVS Caremark?

CVS Caremark (formerly Caremark Rx) is the pharmacy benefit management subsidiary of CVS Health, headquartered in Woonsocket, Rhode Island.

What is the phone number for Aetna Express Scripts?

For general questions, please call our Patient Customer Service at the number on your member ID card or call (800) 282-2881. For technical support or assistance with your online account, please call (800) 711-5672.