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Aetna Specialty Documents and Forms
Find the documents and forms you need to request specialty medications.
Aetna Specialty Precertification forms
- Abatacept (Orencia®) Precertification Request Form
(PDF, 376 KB) - Adalimumab (Humira®) Precertification Request Form (PDF, 651 KB)
- Alefacept (Amevive®) Precertification Request Form (PDF, 317 KB)
- Alpha 1 Antitrypsin Inhibitor Therapy Precertification Request Form (PDF, 579 KB)
- Anakinra (Kineret®) Precertification Request Form (PDF, 355 KB)
- Antiemetic Injectable Medication Precertification Request Form (PDF, 337 KB)
- Belimumab (Benlysta®) Injectable Medication Precertification Request (PDF, 366 KB)
- Botulinum Toxins Medication Precertification Request (PDF, 694 KB)
- Brentuximab vedotin (Adcetris®) Injectable Medication Precertification Request (PDF, 293 KB)
- Cabazitaxel (Jevtana®) Injectable Medication Precertification Request (PDF, 303 KB)
- Certolizumab (Cimzia®) Precertification Request Form (PDF, 390 KB)
- Cetuximab (Erbitux) Injectable medication precertification request form (PDF, 281 KB)
- Denosumab (Prolia, Xgeva) Medication Precertification Request (PDF, 638 KB)
- Eculizumab (Soliris®) Medication Precertification Request Form (PDF, 338 KB)
- Enzyme Replacement Precertification Request Form (PDF, 390 KB)
- EPO/Dialysis medication precertification request form (PDF, 739 KB)
- Etanercept (Enbrel®) Precertification Request Form (PDF, 414 KB)
- Golimumab (Simponi®) Precertification Request Form (PDF, 600 KB)
- Growth Hormone Medication Request Forms:
- Adult Growth Hormone Medication Request Form (PDF, 511 KB)
- Pediatric Growth Hormone Medication Request Form (PDF, 460 KB)
- Adult Growth Hormone Medication Request Form
- Hep C Medication Precertification Request (PDF, 476 KB)
- Hereditary Angioedema Medication Precertification Request Form (PDF, 369 KB)
- Hydroxyprogesterone Caproate (Makena®) Medication Precertification Form (PDF, 379 KB)
- Immune Globulin (IG) Therapy Medication Precertification Request (PDF, 608 KB)
- Infertility Medication Precertification Request Forms:
- Female Precertification Request Form (PDF, 468 KB)
- Male Precertification Request Form (PDF, 420 KB)
- Female Precertification Request Form
- Infliximab (Remicade®) Precertification Request Form (PDF, 669 KB)
- Interferon gamma (Actimmune®) Injectable Medication Precertification (PDF, 579 KB)
- Ipilimumab (Yervoy®) Injectable Medication Precertification Request Form (PDF, 356 KB)
- Multiple Sclerosis Medication Precertification request form (PDF, 713 KB)
- Omalizumab (Xolair®) Medication Precertification Form (PDF, 625 KB)
- Osteoporosis Precertification Request Form (PDF, 385 KB)
- Panitumumab (Vectibix) Injectable medication precertification request form (PDF, 292 KB)
- Pegloticase (Krystexxa®) Injectable Medication Precertification Request Form (PDF, 349 KB)
- Provenge medication precertification request form (PDF, 366 KB)
- Pulmonary Arterial Hypertension Precertification Request Form (PDF, 412 KB)
- Radium-223 dichloride (Xofigo) Injectable Medication Precertification Request Form (PDF, 593 KB)
- Repository Corticotropin (H.P Acthar Gel) Injectable medication precertification request form (PDF, 355 KB)
- Rituximab (Rituxan®) Precertification Request Form (PDF, 457 KB)
- Synagis® Medication Precertification Request Form (PDF, 599 KB)
- Teduglutide(Gattex®)Injectable Medication Precertification Request (PDF, 550 KB)
- Tocilizumab (Actemra®) Precertification Request Form (PDF, 642 KB)
- Tofacitinib (XeljanzTM) Medication Precertification Request Form (PDF, 375 KB)
- Ustekinumab (Stelara®) Precertification Request Form (PDF, 314 KB)
- Viscosupplementation Injectable Medications Precertification Request Form (PDF, 377 KB)
- Ziv-Aflibercept (Zaltrap®) Injectable Medication Precertification Request Form (PDF, 351 KB)
Aetna Specialty Pharmacy offers specialized care for patients with complex chronic conditions.
Aetna Specialty Pharmacy forms
- General Medication Request Form (PDF,1018 KB)
- Crohn's/Ulcerative Colitis Medication Request Form (PDF, 349 KB)
- Enzyme Replacement Medication Request Form (PDF, 541 KB)
- Growth Hormone Medication Request Form (PDF, 239 KB)
- Hemophilia Medication Request Form (PDF, 591 KB)
- Hepatitis C Medication Request Form (PDF, 516 KB)
- HIV/AIDS Medication Request Form (PDF, 591 KB)
- Immune Globulin Medication Request Form (PDF, 520 KB)
- Infertility Medication Request Form (PDF, 542 KB)
- Osteoporosis Medication Request Form (PDF, 416 KB)
- Psoriasis Medication Request Form (PDF, 166 KB)
- Rheumatoid/Psoriatic/Juvenile Arthritis and Ankylosing Spondylitis Medication Request Form (PDF, 400 KB)
- Synagis Medication Request Form (PDF, 587 KB)
- Synagis® Reorder Form (PDF, 544 KB)
- Vivitrol Reorder Form (PDF, 530 KB)
- Transplant Medication Request Form (PDF, 569 KB)
- Viscosupplementation Medication Request Form (PDF, 520 KB)
Physician welcome materials
- Aetna Specialty CareRx drug lists
- Precertification list
- Infused and injected medications quick guide (PDF, 173 KB)
- Most frequently prescribed medications (PDF, 465 KB)
- Physician satisfaction questionnaire (PDF, 728 KB)
- Physician welcome brochure (PDF, 1.4 MB)
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