CurrentAetnaPolicy N/A

Medical Prior Authorization Request Form (medications, including specialty drugs)

This document is Aetna's medical prior authorization request form for medications (including specialty drugs) used by providers to request precertification and supply required clinical and demographic information. It applies to providers submitting authorization requests for Aetna members.

Policy Summary

PayerAetna

PolicyMedical Prior Authorization Request Form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSend the completed prior authorization form and supporting clinical documentation via fax to 1-888-267-3277 (or call 1-866-752-7021 with questions).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4pages

1-888-267-3277fax

1-866-752-7021phone

Member & clinical datarequired info

Coverage Criteria and Decision Logic

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Diagnosis selection: Provider indicates the diagnosis that applies to this request; directs to subsequent questions.

See Q1 in form.

Prior treatment: Has the patient been treated with another medication for this diagnosis? If yes, provide previous medication name(s) and date range; indicate if previous treatment was ineffective, not tolerated, or contraindicated.

See Q2, Q3, Q4, Q5.

Diagnostic confirmation: Has this condition been confirmed by diagnostic testing and are relevant laboratory data available? Provider must supply test names, dates, and results.

See Q6, Q7, Q8.

Cancer-specific questions: If the requested medication is for cancer, indicate current disease stage and how the medication will be used (first-line, second-line, subsequent, single agent or combination); state whether medication is FDA-approved or NCCN-recommended and provide NCCN category when applicable.

See Q11, Q14–Q21.

Initiation vs continuation: Indicate whether the request is for initiation or continuation; if continuation, answer questions about disease stability/improvement and provide date of last treatment; if evidence of progression or unacceptable toxicity is present, indicate and provide supporting documentation.

See Q12, Q13, Q22.

Approvals may be subject to dosing limits consistent with FDA-approved labeling, accepted compendia, and/or evidence-based practice guidelines. The form emphasizes that complete clinical documentation must be submitted with all drug authorization requests; lack of appropriate dosing information or missing clinical details may affect approval and can prompt requests for additional information.

For oncology and other specialty uses, the form asks whether the medication is FDA-approved for the requested setting. If it is not FDA-approved, the form then asks whether the medication is NCCN-recommended and, if so, to indicate the NCCN category. If the agent is neither FDA-approved nor supported by NCCN where requested, the form requires additional documentation and responses to follow-up questions; absence of supportive evidence may result in denial.

What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior authorization is required for certain medications. To initiate review, send the completed prior authorization form and all supporting clinical documentation via fax to 1-888-267-3277. For questions regarding prior authorization call 1-866-752-7021 (TTY: 711).

Fax: 1-888-267-3277
Phone: 1-866-752-7021 (TTY: 711)

Step Therapy

Prior Medication Use

The form collects prior medication use and asks whether prior agents were ineffective, not tolerated, or contraindicated. Provide the name(s) of previous medication(s) and date ranges of prior treatment to support step-therapy or failure-of-therapy determinations.

Question 3: Name of previous medication(s)
Question 4: Date range of previous treatment
Question 5: Was prior treatment ineffective, not tolerated, or contraindicated?

Documentation Required

Information to Include on the Form

Providers must submit patient demographic data, diagnosis (primary and any other applicable ICD-10 codes), weight/height where required, and full medication details (requested drug, dose, route, frequency, and duration). Include relevant diagnostic testing, laboratory results, cancer stage (if applicable), treatment intent (initiation vs continuation), and any NCCN/FDA status or rationale when applicable.

Patient demographics: name, DOB, address, Aetna Member ID, group #, other coverage information
Diagnosis: primary ICD code and any secondary/other ICD codes
Medication details: requested drug, dose, route, frequency, duration, and whether single-agent or combination therapy
Clinical data: relevant labs, diagnostic test names, dates and results, cancer stage, documentation of disease stability or improvement
Regulatory/guideline status: FDA approval and NCCN category when applicable

Denial Risk

Incomplete or Missing Documentation May Delay or Deny Request

Incomplete clinical information or missing supporting documentation (progress notes, laboratory testing, diagnostic testing, medication history, etc.) may result in denial or a request for additional information and delay the review.

All clinical documentation must be submitted with the drug request
We may request additional information or clarification if needed
Incomplete submissions can be denied or held pending additional documentation

Background and Purpose

This prior authorization form is used to support clinical review for medication authorization, including both initiation and continuation of therapy across cancer and non-cancer settings. It guides reviewers through a decision-tree of questions addressing diagnosis, prior treatments, diagnostic confirmation, disease stage and intended use, and whether the request is for initiation or continuation. Providers must supply patient demographic and diagnosis information, treatment dates, prior medication history, relevant laboratory and diagnostic test results, and supporting clinical documentation to enable evaluation; incomplete or missing information may lead to requests for clarification or denial. Send the completed form and supporting documentation to the fax number provided.

Definitions and Place of Service

Place of Service — required entries

HomePlace of service: Home (POS Code 12)

Outpatient hospitalPlace of service: Outpatient Hospital (POS Code 19, 22)

OfficePlace of service: Office (POS Code 11)

Self-administeredIndicate if medication is self-administered

Dispensing pharmacy detailsIf place of service is not dispensing the drug, provide dispensing pharmacy name, address, phone, NPI, tax ID, and fax

Initial Therapy Requirements

Initial therapy criteria

For new requests, provide the treatment start date and complete clinical information to support medical necessity.

Initial therapy requirements: Provide treatment start date and primary ICD code; supply patient demographic data and medication details (strength, dose, frequency, route).

See form fields for new requests and Q (initiation).

Prior therapy and rationale: Document prior medication history or state rationale if no prior therapy; include previous medication name(s) and date ranges and indicate if prior agents were ineffective, not tolerated, or contraindicated.

See Q2–Q5.

Diagnostic and laboratory documentation: Provide diagnostic test names, dates, and results, and any relevant laboratory data specific to the medication request (e.g., CBC, liver transaminases, bilirubin, TB testing, pregnancy test, genetic testing).

See Q6–Q9 and Q8.

Regulatory/compendium status: Indicate whether the medication is FDA-approved for this setting; if not, state whether it is recommended by NCCN and provide NCCN category as applicable.

See Q18–Q21.

Attachments: Attach all relevant documentation for consideration (progress notes, laboratory testing, diagnostic testing, medication history).

See Q10.

Continuation Therapy Requirements

Continuation therapy requirements

For continuation requests, provide the date of last treatment and documentation that demonstrates ongoing benefit or explains treatment change.

Last treatment date: Provide the date of last treatment for the requested medication.

See form continuation field.

Clinical status: Document disease stability or improvement with supporting clinical documentation; if disease progression or unacceptable toxicity is present, indicate and provide supporting documentation.

See Q13 and Q22.

If progression or toxicity: If evidence of disease progression, relapse, refractory disease, unresectable, metastatic or unacceptable toxicity is present, specify and attach supporting records; these responses may change the review path.

See Q15 and Q22.

Ongoing monitoring: Include any recent diagnostic or laboratory results that document current disease status or treatment-related toxicity monitoring.

See Q8 and Q9.

Step Therapy and Prior Medication Documentation

Prior medication(s) (name)	Date range of prior treatment	Reason prior therapy stopped
Provide the name(s) of previous medication(s) used to treat the current diagnosis (list all that apply).	Enter the start and end dates (MM/DD/YYYY – MM/DD/YYYY) for each prior medication listed.	Indicate whether prior treatment was: Ineffective \| Not tolerated \| Contraindicated (select one) and provide brief supporting details.

Site of Care Requirements

Billing Rule

Indicate place of service and dispensing pharmacy when applicable

Indicate the place of service where the drug will be administered (Home, Outpatient Hospital, Office) or mark if self‑administered; if the place of service is not dispensing, provide the dispensing pharmacy name and contact details.

Home (POS Code 12)
Outpatient Hospital (POS Code 19 or 22)
Office (POS Code 11)
Self-administered — select accordingly and provide dispensing pharmacy if different from administering location.