CurrentAetnaPolicy N/A

Zulresso_Medication_Precertification_Request

Aetna precertification request form to collect patient, prescriber, dispensing/provider, product, diagnosis, and required clinical information for authorization of Zulresso (brexanolone) therapy for postpartum depression. It documents checklist items required for review but does not itself state coverage criteria or reimbursement rules.

Policy Summary

PayerAetna

PolicyZulresso_Medication_Precertification_Request

Policy CodePolicy N/A

Change TypeForm / Precertification (informational)

Effective Date

Next Review Date

Key ActionProviders must complete and submit this precertification form with all required fields for review prior to start or continuation of Zulresso treatment; incomplete or illegible forms will not be accepted.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

9Required clinical checklist items

1Form pages

Policy overview

This is an Aetna precertification request form titled Zulresso (brexanolone) Medication Precertification Request designed to collect patient, prescriber, dispensing/administration, product, diagnosis, and required clinical information to support review for authorization of brexanolone (Zulresso) for postpartum depression. The form includes sections for patient and insurance details, prescriber and dispensing/provider information, product and ICD diagnosis codes, and an itemized clinical checklist.

The clinical checklist documents specific items required for review, including attestations about diagnosis (postpartum depression), severity (moderate to severe), psychiatrist involvement or consultation, standardized rating scale documentation of a major depressive episode, timing of the episode relative to pregnancy/delivery, postpartum timing (≤ 6 months), lactation status and plans for breastmilk during and up to 4 days after infusion, and prior receipt of brexanolone for the current pregnancy/childbirth. The form must be completed and legible for precertification review and signed by the requester.

Form scope and metadata

scope_summaryAetna precertification request form to collect patient, prescriber, dispensing/provider, product, diagnosis, and required clinical information for authorization of Zulresso (brexanolone) therapy for postpartum depression. It documents checklist items required for review but does not itself state coverage criteria or reimbursement rules.

subjectZulresso (brexanolone) medication precertification request form

payerAetna

policy idZulresso_Medication_Precertification_Request

statusCURRENT

form pages1

Coverage stance

Coverage stance: informational. This document functions as a precertification form to collect the clinical and administrative information Aetna requires for review of Zulresso (brexanolone) requests, not as an independent coverage determination.

Providers must complete and submit the form with all required fields (including the clinical checklist items listed on the form) for review prior to start or continuation of Zulresso treatment; incomplete or illegible forms will not be accepted. For Medicare Advantage Part B patients, providers should use the Medicare Request Form as noted on the form.

Required clinical information checklist for precertification

For all requests (clinical documentation required):

ALL of the following

Diagnosis is postpartum depression
Checkbox item
Patient has moderate to severe postpartum depression
Checkbox Yes/No
Requested medication will be prescribed by or in consultation with a psychiatrist
Checkbox Yes/No
Patient has had a major depressive episode, documented by standardized rating scales (e.g., BDI, HDRS, MADRS)
Checkbox Yes/No
Major depressive episode occurred no earlier than the third trimester and no later than the first 4 weeks following delivery
Checkbox Yes/No
Patient is currently 6 months postpartum or less
Checkbox Yes/No
Patient has stopped lactating
Checkbox Yes/No
Breastmilk produced during infusion and up to 4 days after infusion completion will NOT be used for feedings
Checkbox Yes/No
Patient has not previously received treatment with the requested medication for the current pregnancy/childbirth
Checkbox Yes/No

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What providers must do

Prior Authorization

Precertification submission required

Providers must complete and submit this precertification form with all required fields for review prior to start or continuation of Zulresso treatment; incomplete or illegible forms will not be accepted.

Documentation Required

Required clinical documentation

Providers must document diagnosis, severity (moderate to severe), psychiatrist involvement or consultation, standardized depression rating scale results, timing of episode relative to pregnancy/delivery, postpartum timing (≤6 months), lactation status and breastmilk feeding plan for up to 4 days after infusion, and prior receipt of brexanolone for the current pregnancy/childbirth.

Diagnosis: postpartum depression
Severity: moderate to severe postpartum depression
Prescribed by or in consultation with a psychiatrist
Major depressive episode documented by standardized rating scales (e.g., BDI, HDRS, MADRS)
Episode timing: no earlier than third trimester and no later than first 4 weeks postpartum
Patient is currently ≤6 months postpartum
Lactation status and whether patient has stopped lactating
Breastmilk produced during infusion and up to 4 days after infusion will NOT be used for feedings
Prior receipt of brexanolone for the current pregnancy/childbirth

Billing Rule

Use Medicare form for Medicare Advantage Part B

For Medicare Advantage Part B patients, providers should use the Medicare Request Form for precertification submissions.

Documentation Required

Fraud acknowledgement

Request must be signed and dated; providers are warned that knowingly providing false or misleading information is fraudulent and may result in penalties.