CurrentAetnaPolicy N/A

Prior Authorization Request Form and Instructions for Pharmacy Drug Benefits

This document is Aetna's prior authorization request form and instructions for pharmacy (specialty and non-specialty) drug benefits; it governs how providers submit PA requests, required information, and contact methods for affected members and prescribers.

Policy Summary

PayerAetna

PolicyPrior Authorization Request Form and Instructions for Pharmacy Drug Benefits

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests via Availity, fax, or phone and include required clinical and administrative documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Availity, fax, phonesubmission channels listed

1-855-240-0535fastest phone number

1-877-269-9916; 1-866-249-6155fax numbers

711TTY

Coverage Criteria

If the prescriber indicates the request is a first request within a 12‑month period to treat opioid dependence, a prior authorization is not required for a 5‑day supply of any FDA‑approved medication for opioid dependence and the provider does not need to complete this form for that 5‑day supply.

As of January 1, 2020, a prior authorization is not required for prescription medications that are listed on the carrier's formulary; when this applies, the provider does not need to complete this form.

Requested Drug Billing Codes

Requested drug billing codesmixed

J-code

Request form requests J-code if applicable

Provider Submission & Required Actions

Note

Submission methods and urgent handling

Submit prior authorization requests via Availity (www.Availity.com), by fax (1-877-269-9916 for non-specialty drug PA; 1-866-249-6155 for specialty drug PA), or by phone for fastest service at 1-855-240-0535, Monday–Friday, 8 a.m. to 6 p.m. Central Time. On the PA form, indicate whether the request is Urgent or Non‑Urgent. Urgent requests are for situations where a delay could seriously jeopardize life or health, cause severe pain that cannot be managed without the drug, or involve medication‑assisted treatment for substance use disorder; these must be clearly marked so they are processed within the applicable expedited timeframes.

Policy Summary

PayerAetna

PolicyPrior Authorization Request Form and Instructions for Pharmacy Drug Benefits

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests via Availity, fax, or phone and include required clinical and administrative documentation.

SourceLink

On This Page

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Online: www.Availity.com
Phone (fastest): 1-855-240-0535, Mon–Fri 8 a.m.–6 p.m. CT
Fax (non-specialty): 1-877-269-9916
Fax (specialty): 1-866-249-6155
Form must indicate Urgent or Non‑Urgent

Step Therapy

Step therapy / prior medication history

Provide a complete prior medication history and step‑therapy information on the PA form. List prior medications tried for the condition, including drug name(s), duration of therapy, and patient response (efficacy and adverse effects). Indicate whether step therapy requirements have been met or provide clinical rationale for bypassing step therapy when applicable.

List prior medications, duration, and patient response
State whether step therapy has been completed or provide justification to bypass

Documentation Required

Required documentation for prior authorization

Include all required documentation with the PA request to support medical necessity and enable timely review. The PA form must include patient and prescriber details, diagnosis with ICD‑10 code(s), requested drug(s) (include J‑code if applicable), strength/route/frequency, quantity, duration or length of therapy, start date, location of treatment (with provider/facility name, address, Tax ID, and Type 2 NPI if applicable), dispensing pharmacy name and phone number, and prescriber signature and date. Attach supporting clinical information such as relevant medical records, lab results, prior authorization decision history, and any additional pertinent clinical notes or documentation (including clinical trial name/registration number if applicable).

Patient and prescriber details and prescriber signature/date
Diagnosis and ICD‑10 code(s)
Drug name(s) with J‑code (if applicable), strength, route, frequency, quantity, and number of refills
Start date and length of therapy
Location of treatment with provider/facility name, address, Tax ID, and Type 2 NPI (if applicable)
Dispensing pharmacy name and phone number
Attach clinical criteria/supporting documents, prior medication history, and clinical trial information if relevant

Denial Risk

Denial communication requirement

If the PA request is denied, the form requires documenting the reason for denial and, when applicable, listing alternative formulary medications. Communicate the denial reason and propose other potential therapeutic options that are covered on the carrier's formulary.

Provide specific reason for denial on the form
Include alternative formulary medications when applicable

Definitions

inv-09: Urgent request — definition where delay could seriously jeopardize life, health, or ability to regain maximum function

DefinitionA prior authorization request where delay in determination could seriously jeopardize the covered person’s life or health, the ability to regain maximum function, cause severe unmanaged pain that cannot be adequately managed without the drug benefit requested, or is a prior authorization request for medication‑assisted treatment for substance use disorder.

Examples of situations meeting definitionRequests where delay could seriously jeopardize life or health, prevent regaining maximum function, or cause severe unmanageable pain.

Includes medication‑assisted treatmentUrgent designation applies to prior authorization requests for medication‑assisted treatment for substance use disorder.

How urgency is indicatedThe PA form captures Urgent vs Non‑Urgent selection; urgent requests should be marked on the form to trigger the expedited pathway.

Operational noteAetna processes urgent requests per the expedited pathway when the criteria above are met.

Step Therapy / Prior Medication Requirements

Medication	Duration (dates or length of therapy)	Patient response
Medication name (brand and scientific name)/Strength	Start date and/or length of therapy (as reported)	Patient response to medication (clinical effect, tolerability, reason for discontinuation)

Site of Care Requirements

Note

Specify treatment location and include Type 2 NPI/address

Specify the location of treatment on the PA form (e.g., provider office, facility, home health) and include the location name, Type 2 NPI if applicable, full address, and tax ID.

Indicate setting: Office, facility, home health, etc.
Provide location name, Type 2 NPI (if applicable), address, and tax ID

Background

This form is used to capture the clinical and administrative details necessary to evaluate medical necessity for prescription drug benefits, including specialty drugs and medications for substance use disorder. It documents the request type (urgent versus non‑urgent), the requested drug, and whether the drug is intended to treat opioid dependence so the reviewer can determine if the 5‑day first‑request exemption or the formulary PA exemption effective January 1, 2020 applies.