Epoetin-alfa (Epogen/Procrit/Retacrit) precertification request form
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This document is Aetna's precertification request form and required clinical information checklist for initiation or continuation of epoetin-alfa (Epogen®, Procrit®, Retacrit®) therapy, intended for prescribers and staff submitting authorization requests.
No material clinical or coverage changes in this revision.
Coverage Criteria and Indication-specific Requirements
Required clinical criteria for precertification
Coverage requests are reviewed when required clinical information is provided for the requested indication; different indication-specific details are collected.
Supports precertification review
Collected for all initiation requests
Required for continuation review
For presurgical use, the form specifically captures whether the patient is scheduled for an elective, noncardiac, nonvascular surgery when epoetin-alfa is being requested to reduce allogeneic blood transfusions. The form also requires the patient's pretreatment hemoglobin (Hgb) and the date of the test (excluding values influenced by a recent transfusion) to support the presurgical indication.
The plan may request additional information or clarification as needed to evaluate a precertification request. The form includes an acknowledgment that any person who knowingly submits materially false or misleading information to obtain coverage may be committing a fraudulent insurance act and is subject to criminal and civil penalties.
Administration Codes and Therapy Metrics
| Administration code(s) (CPT) | Placeholder for administration CPT codes to be provided on form |
Precertification Submission Requirements and Provider Notices
Precertification required
Precertification is required. Contact Aetna Precertification Notification by phone or fax as listed on the form before initiating therapy.
- Phone: 1-866-752-7021
- FAX: 1-888-267-3277
- For Medicare Advantage Part B: Please use Medicare Request Form
Alternate ESA assessment
For all initiation requests, document whether the patient has a contraindication, intolerance, or ineffective response to Retacrit (alternate ESA). For CKD and chemotherapy indications, document whether the patient has a contraindication, intolerance, or ineffective response to Aranesp. Include dates and supporting clinical data.
- Does the patient have a contraindication, intolerance or ineffective response to Retacrit? (Yes/No)
- Does the patient have a contraindication, intolerance or ineffective response to Aranesp? (Yes/No)
- For initiation requests: record pretreatment hemoglobin (Hgb) level and date (exclude values due to recent transfusion)
- For initiation requests: assess iron deficiency — provide most recent TSAT (%) and date, and whether patient is receiving iron therapy
Required documentation on form
The precertification form must be fully completed and legible. Required elements include patient demographics, insurance information, prescriber and dispensing provider details, and full request-specific clinical information (diagnosis, indication, prior ESA use, hemoglobin and TSAT values with dates, iron therapy status, and product requested).
- All fields must be completed and legible for precertification review
- Patient information (name, DOB, contact, allergies, weight/height)
- Prescriber information (name, credentials, NPI, license, specialty, phone/fax)
- Product information (Epogen/Procrit/Retacrit, dose, frequency)
- Diagnosis (primary ICD code and any secondary codes)
- Clinical info for initiation or continuation requests including prior ESA use within 30 days, pretreatment and current Hgb with dates, TSAT and iron therapy status, and duration/weeks of ESA therapy for continuation requests
Submission risks
Incomplete or illegible submissions may prevent review. Any person who knowingly submits materially false information or conceals material information may be subject to criminal and civil penalties. The plan may request additional information or clarification if needed to evaluate requests.
- Incomplete or illegible submissions may delay or prevent precertification review
- Materially false information or concealment may be considered fraud and is subject to penalties
- The plan may request additional information or clarification to evaluate requests
Clinical Background
Epoetin-alfa (Epogen®, Procrit®, Retacrit®) is an erythropoiesis-stimulating agent (ESA) used to treat anemia associated with multiple conditions. The precertification form lists common indications captured for review, including anemia of chronic kidney disease, chemotherapy-related anemia, myelodysplastic syndromes, anemia related to hepatitis C therapy or zidovudine in HIV, certain cases of rheumatoid arthritis, and specific surgical settings where transfusion reduction is the goal. The form collects baseline data—such as pretreatment Hgb, iron studies (TSAT), and prior ESA exposure—to support medical-necessity review for initiation or continuation of epoetin therapy.
Initiation and Continuation Request Definitions
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