Loading...Download the AETNA Prescription Drug Authorization Request Form that has been created for prescribers to make it possible for Doctors to assist with medication to be sent to patients by mail. Prescribers would simply fill in the form and fax it to AETNA.
How To Write
Step 1 – Section 1 – Patient Information –
- Begin by selecting “Urgent” or “Non-Urgent,” If the order is urgent, please supply the name of the drug(s) that need urgent attention and delivery – then provide the following patient information –
- Patient’s full name with middle initial
- Member Subscriber Number
- Policy/Group Number
- Patient Date of Birth mm/dd/yyyy
- Patient’s full address
- Patient’s telephone number
- Patient’s email address
- Prescription date
Step 2 – Section 2 – Prescribing Provider Information –
- Prescriber Name
- Prescriber Fax
- Prescriber Phone
- Prescriber Pager
- Prescriber’s Full Address
- Prescriber Office Contact
- Prescriber NPI
- Prescriber DEA
- Specialty/Facility Name (if applicable)
- Prescriber Email Address
Step 3 – Section 3 – Prior Authorization Request for Drug Benefit –
- Patient Diagnosis and ICD Diagnostic Code(s)
- Drug(s) Requested (with J-Code, if applicable)
- Strength/Route/Frequency
- Unit/Volume of Named Drug(s)
- Start Date and Length of Therapy
- Location of Treatment (i.e., provider’s office, facility, home health etc) including name, Type 2 NPI (if it applies) address and Tax ID
- Clinical Criteria for Approval, including other pertinent information to support the request, other medications tried, the names of the medications, duration and patient response to the past medications
- Any additional information we should consider (please attach any supporting documentation)
- For use in clinical trial? (If yes, provide trial name and registration number)
- Drug name (brand name and scientific name/strength)
- Dose
- Route
- Frequency
- Quantity
- Number of Refills
- Product will be delivered to (check the appropriate box
- Prescriber or Authorized Signature
- Date
- Dispensing Pharmacy Name and Phone Number
- Approved / Denied check the appropriate box
- If denied, provide reason for denial and include other potential alternative medications, if applicable, that are found in the formulary of the carrier.
- Once complete fax form to AETNA at 877.269.99146
- Specialty Drugs fax to 888.267-3277