NURSING > STUDY GUIDE > Aetna Medical Exception/Prior Authorization/Precertification* Request for Prescription Medications (All)

**Aetna Medical Exception/Prior Authorization/Precertification* Request for Prescription Medications**

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Aetna Medical Exception/Prior Authorization/Precertification* Request for Prescription MedicationsMedical Exception/Prior Authorization/Precertification* Request for Prescription Medications Fax this form to: 1-877-269-9916 OR Submit your request online at: https://navinet.navimedix.com/Main.asp Visit www.aetna.com/formulary to access our Pharmacy Clinical Policy Bulletins. For FASTEST service, call 1-855-240-0535, Monday-Friday, 8 a.m. to 6 p.m. Central Time Patient Information Patient Name Patient Insurance ID Number Patient Address, City, State, ZIP Home Telephone Gender Male Female Patient Date of Birth Prescriber Information Today’s Date Physician Name Physician Address M.D. Office Telephone Number M.D. Office Fax Number Diagnosis and Medical Information Medication Strength Frequency Expected Length of Therapy Quantity Day Supply If this is a continuation of therapy, how long has the patient been on the medication? Is this medication being used to treat a chronic or long term condition for which this prescription medication may be necessary for the life of the patient? Yes No PLEASE CHECK ALL BOXES THAT APPLY: Do you want a drug specific prior authorization criteria form faxed to your office? Yes No (If yes, no further questions are required). What condition is the drug being prescribed for? ICD code Diagnosis Does the patient have a diagnosis of cancer? Yes No STEP THERAPY may be required. Please list all medications the patient has tried specific to the diagnosis and specify below: Therapeutic failure, including length of therapy for each drug: Drugs (s) contraindicated: Adverse even (e.g., toxicity, allergy) for each drug: Is the request for a patient with one or more chronic conditions (e.g., psychiatric condition, diabetes) who is stable on the current drug(s) and who might be at high risk for a significant adverse event with a medication change? If so, specify anticipated significant adverse event: Has the condition been confirmed by diagnostic testing? If so, please provide diagnostic test and date: Please provide any pertinent lab testing values for the members diagnosis : Does the patient have a clinical condition for which other alternatives are not recommended based on published guidelines or clinical literature? If so, please provide documentation: Does the patient require a specific dosage form (e.g., suspension, solution, injection)? If so, please provide dosage form: Are additional risk factors (e.g., GI risk, cardiovascular risk, age) present? If so, please provide risk factors: Other: Please provide additional relevant information: REQUIRED CLINICAL INFORMATION: PLEASE PROVIDE ALL RELEVANT CLINICAL DOCUMENTATION TO SUPPORT USE OF THIS MEDICATION. PLEASE COMPLETE CORRESPONDING SECTION ON BACK PAGE FOR THE SPECIFIC DRUG/CLASS LISTED BELOW. Antiemetic (5-HT3) Agents/Erectile Dysfunction Agents/Stimulants/ Provigil, Nuvigil/Testosterones **FOR ANY DRUG/CLASS NOT LISTED ON THE BACK PAGE, PLEASE ATTACH ADDITIONAL INFORMATION, BUT CANNOT EXCEED TWO PAGES** PRESCRIPTION BENEFIT PLAN MAY REQUEST ADDITIONAL INFORMATION OR CLARIFICATION, IF NEEDED,

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