() Injectable Medication Precertification Request Accessible PDF 2026

1. Click ‘Get Form’ to open the Injectable Medication Precertification Request in our editor.
2. Begin by filling out the patient information section. Enter the patient's first and last name, address, phone numbers, date of birth, and any allergies. Ensure all fields are legible.
3. Next, complete the insurance information section. Provide the Aetna Member ID, group number, and indicate if the patient has other coverage.
4. In the prescriber information section, input the prescriber's details including name, address, phone number, and specialty.
5. Fill out the dispensing provider/administration information. Specify where the medication will be administered and provide contact details for the dispensing provider.
6. Complete the product information by indicating the requested dose and frequency of Lucentis.
7. Provide diagnosis information by entering primary and secondary ICD codes as applicable.
8. Finally, ensure that all clinical information is filled out completely before signing and submitting your request.

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