Aetna Rx - MEDICARE - Viscosupplementation Injectable Medication Precertification Request Accessible 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the start date of treatment and the name of the individual requesting precertification in the designated fields.
3. Fill out Section A with patient information, including first name, last name, address, phone numbers, date of birth, allergies, weight, height, and email.
4. In Section B, provide insurance details such as Aetna Member ID and group number. Indicate if there is other coverage and include relevant information.
5. Complete Section C with prescriber information including their name, contact details, and license numbers.
6. Section D requires dispensing provider information. Specify the place of administration and provide necessary contact details.
7. In Section E, select the requested product from the list provided and fill in dosage and frequency.
8. Complete Sections F and G with diagnosis codes and clinical information required for precertification requests.
9. Finally, ensure all sections are filled completely before signing in Section H to finalize your request.

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