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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, 307 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, 291 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, 365 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, 450 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, 502 KB)
- Pediatric Growth Hormone Medication Request Form (PDF, 443 KB)
Hep C Medication Precertification Request (PDF, 398 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)
Infliximab (Remicade^®) Precertification Request Form (PDF, 669 KB)
Insulin-Like Growth Factor-1 Injectable Medication Precertification Request Form (PDF, 547 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, 632 KB)
Obinutuzumab (GazyvaÂ®) Injectable Medication Precertification Request Form (PDF, 372 KB)
Omalizumab (Xolair®) Medication Precertification Form (PDF, 670 KB)
Osteoporosis Precertification Request Form (PDF, 385 KB)
Palivizumab (SynagisÂ®) Injectable Medication Precertification Request Form (PDF, 649 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, 308 KB)
Pulmonary Arterial Hypertension Precertification Request Form (PDF, 450 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, 357 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 (Xeljanz^TM) Medication Precertification Request Form (PDF, 375 KB)
Trastuzumab (Herceptin), Ado-Trastuzumab (Kadcyla) and Pertuzumab (Perjeta) Injectable Medication Precertification Request Form (PDF, 579 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,1 MB)
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, 626 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)

Tools for Health Care Professionals

Tools & Educational Material