Fax this form to: 1-877-269-9916 - · PDF fileFax this form to: 1-877-269-9916 Approved. For...
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Approved Fax this form to: 1-877-269-9916 For specialty drugs fax to: 1-888-267-3277 Aetna Specialty Pharmacy phone: 1-866-503-0857 OR Submit your request online at: https://navinet.navimedix.com/Main.asp PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM CONTAINS CONFIDENTIAL PATIENT INFORMATION For FASTEST service, call 1-855-240-0535, Monday-Friday, 8 a.m. to 6 p.m. Central Time Urgent 1 Non-Urgent Requested Drug Name: Patient Information: Prescribing Provider Information: Patient Name: Prescriber Name: Member/Subscriber Number: Prescriber Fax: Policy/Group Number: Prescriber Phone: Patient Date of Birth (MM/DD/YYYY): Prescriber Pager: Patient Address: Prescriber Address: Patient Phone: Prescriber Office Contact: Patient Email Address: Prescriber NPI: Prescriber DEA: Prescription Date: Prescriber Tax ID: Specialty/Facility Name (If Applicable): Prescriber Email Address: Prior Authorization Request for Drug Benefit: New Request Reauthorization Patient Diagnosis and ICD Diagnostic Codes(s): Drug(s) Requested (with J-Code, if applicable): Strength/Route/Frequency: Unit/Volume of Named Drug(s): Start Date and Length of Therapy: Location of Treatment (e.g. provider office, facility, home health, etc.) including name, Type 2 NPI (if applicable), address and tax ID: Clinical Criteria for Approval, Including other Pertinent Information to Support the Request, other Medications Tried, Their Name(s), Duration, and Patient Response: Any additional information we should consider (please attach all supporting documents). For use in clinical trial? (if yes, provide trial name and registration number): Drug Name (Brand Name and Scientific Name)/Strength: Dose: Route: Frequency: Quantity: Number of Refills: Product will be delivered to: Patient’s Home Physician Office Other: Prescriber or Authorized Signature: Date: Dispensing Pharmacy Name and Phone Number: Denied If denied, provide reason for denial, and include other potential alternative medications, if applicable, that are found in the formulary of the carrier. 1. A request for prior authorization that if determined in the time allowed for non-urgent requests could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function, or subject the person to severe pain that cannot be adequately managed without the drug benefit contained in the prior authorization request. GR-69025-1 CO (9-16)
Transcript of Fax this form to: 1-877-269-9916 - · PDF fileFax this form to: 1-877-269-9916 Approved. For...
Approved
Fax this form to: 1-877-269-9916 For specialty drugs fax to: 1-888-267-3277
Aetna Specialty Pharmacy phone: 1-866-503-0857 OR
Submit your request online at: https://navinet.navimedix.com/Main.asp
PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM
CONTAINS CONFIDENTIAL PATIENT INFORMATION
For FASTEST service, call 1-855-240-0535, Monday-Friday, 8 a.m. to 6 p.m. Central Time
Urgent1
Non-Urgent
Requested Drug Name:
Patient Information: Prescribing Provider Information: Patient Name: Prescriber Name:
Member/Subscriber Number: Prescriber Fax:
Policy/Group Number: Prescriber Phone:
Patient Date of Birth (MM/DD/YYYY): Prescriber Pager:
Patient Address: Prescriber Address:
Patient Phone: Prescriber Office Contact:
Patient Email Address: Prescriber NPI:
Prescriber DEA:
Prescription Date: Prescriber Tax ID:
Specialty/Facility Name (If Applicable):
Prescriber Email Address:
Prior Authorization Request for Drug Benefit: New Request Reauthorization
Patient Diagnosis and ICD Diagnostic Codes(s):
Drug(s) Requested (with J-Code, if applicable):
Strength/Route/Frequency:
Unit/Volume of Named Drug(s):
Start Date and Length of Therapy:
Location of Treatment (e.g. provider office, facility, home health, etc.) including name, Type 2 NPI (if applicable), address and tax ID:
Clinical Criteria for Approval, Including other Pertinent Information to Support the Request, other Medications Tried, Their Name(s), Duration, and Patient Response:
Any additional information we should consider (please attach all supporting documents).
For use in clinical trial? (if yes, provide trial name and registration number):
Drug Name (Brand Name and Scientific Name)/Strength:
Dose: Route: Frequency:
Quantity: Number of Refills:
Product will be delivered to: Patient’s Home Physician Office Other:
Prescriber or Authorized Signature: Date:
Dispensing Pharmacy Name and Phone Number:
Denied
If denied, provide reason for denial, and include other potential alternative medications, if applicable, that are found in the formulary of the carrier.
1. A request for prior authorization that if determined in the time allowed for non-urgent requests could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function, or subject the person to severe pain that cannot be adequately managed without the drug benefit contained in the prior authorization request.
GR-69025-1 CO (9-16)
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Aetna provides free aids/services to people with disabilities and to people who need language assistance.
If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card.
If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting: Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779), 1-800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers: 860-262-7705), [email protected].
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).
Aetna is the brand name used for products and services provided by one or more of the Aetna group
of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and
their affiliates (Aetna).
GR-69025-1 CO (9-16)
GR-69025-1 CO (9-16)
GR-69025-1 CO (9-16)
GR-69025-1 CO (9-16)
GR-69025-1 CO (9-16)
GR-69025-1 CO (9-16)
GR-69025-1 CO (9-16)
GR-69025-1 CO (9-16)
