Medication Precertification Request Form Updated Medication Precertification Request Form 2026

1. Click ‘Get Form’ to open the Medication Precertification Request Form in our platform's editor.
2. Begin by filling out Section A: Patient Information. Enter the patient's last name, first name, date of birth, and contact details including phone numbers and email.
3. Proceed to Section B: Insurance Information. Input the Aetna Member ID, Group number, and indicate if the patient has other coverage by selecting 'Yes' or 'No'.
4. In Section C: Prescriber Information, provide the prescriber's details including their name, specialty, and contact information.
5. Complete Section D: Dispensing Provider/Administration Information by selecting the place of administration and providing relevant provider details.
6. Fill out Section E: Product Information by indicating the requested dosage and frequency for Xolair.
7. In Section F: Diagnosis Information, enter the primary ICD-9 code along with any secondary codes as applicable.
8. Complete Section G: Clinical Information with required clinical data specific to asthma or urticaria requests.
9. Finally, sign in Section H: Acknowledgement to confirm that all information is accurate before submitting your request.

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