Health care professional forms
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Applications and forms for health care professionals and their patients
Address/phone number changes
To change your phone or fax number, email address or practice address, use the link below. If your changes result from an out-of-state move or a change of provider group, please use the form above instead.
Behavioral Health Precertification
Coordination of Benefits
Dispute and Appeals
For Part D prior authorization forms, please see the Medicare section.
Authorized Representative Request
Medicare Member Authorization Appeal-appealing Medicare denials of medical prior authorization (precertification) requests
Medicare Appeals Provider Memo- Post Service
Member Complaint and Appeal
Practitioner and Provider Complaint and Appeal
Employee Assistance Program (EAP)
Medical Precertification
Autolougous Chondrocyte Implantation
BRCA
Breast Reduction and/or Reconstructive Surgery
Dorsal Column Stimulator
Electroencephalographic (EEG) Video Monitoring
Gender Reassignment Surgery
Gender Reassignment Surgery - Aetna Student Health
Hip Surgery for Impingement Syndrome
Hyperbaric Oxygen Therapy (HBOT)
Infertility Services
Initial Cochlear Implant
Lower Limb Prosthesis including Microprocessor-Controlled Knee
Obesity Surgery
Panniculectomy
Proton Beam Radiotherapy
Ptosis Surgery
Shoulder Arthroplasty
Sinus Surgery
Skilled Home Private Duty Nursing Care
Spinal Surgery
Uvulopalatopharyngoplasty (UPPP)
Varicose Vein Treatment
Wheelchairs and Power Operated Vehicles (Scooters)
Whole Exome Sequencing (WES)
Medicare
Hospital Discharge Appeal Notices
(Note: This is a page on the CMS site that provides information about patient rights as a hospital inpatient. The page includes detailed information and links to CMS forms.)
Part D prescription drug prior authorizations and exceptions
General prescription drug coverage determination
General prescription drug coverage determination (through SilverScript)
Aranesp® (darbepoetin alfa)
Hepatitis C
Lidocaine Products (generic Lidoderm®)
Linezolid (generic Zyvox®)
Modafinil and Armodafinil (generic Provigil®)
Oral ondansetron (oral generic Zofran®)
Procrit® (epoetin alfa)
Regranex® (becaplermin)
Sildenafil (generic Revatio®)
Topical Testosterone
Tracleer® (bosetan)
Zolpidem tartrate (generic Ambien® immediate release)
Tier exception (cost share reduction) request
CMS General Coverage Determination Request Form
Medicare Medical Specialty Drug and Part B Step Therapy Precertification forms
Abraxane® (albumin-bound paclitaxel) Medicare
Actemra® (Tocilizumab) Medicare
Adcetris® (Brentuximab Vedotin) Injectable Medication Precertification Request
Alpha 1 Antitrypsin Inhibitor Therapy Precertification Request
Aveed Medication Precertification Request
Bavencio®(Avelumab) Medication Precertification Request
Besponsa®(Inotuzumab Ozogamicin) Medication Precertification Request
Botulinum Toxins Medicare
Cimzia® (Certolizumab) Precertification Request
Cinqair® (Reslizumab) Medication Precertification Request
Crysvita® (burosumab-twza) Injectable Medication Precertification Request
Cyramza® (Ramucirumab) Medication Precertification Request
Darzalex™ (Daratumumab) Medication Precertification Request
Emend® (Fosaprepitant) Injectable Medication Precertification Request
Empliciti™ (Elotuzumab) Medication Precertification Request
Entyvio® (Vedolizumab) Medicare
Erbitux® (Cetuximab) Injectable medication precertification Request
Erythropoiesis Stimulating Agents (ESAs) Medications/Dialysis Medicare
Evenity® (Romosozumab) Medicare
Eylea® (Aflibercept) Medicare
Exondys51® (Eteplirsen) Injectable Precertification Request
Fasenra™ (Benralizumab) Injectable Medication Precertification Request
Fulphila™ (pegfilgrastim-jmdb) Medicare
Gattex® (Teduglutide) Injectable Medication Precertification Request
Gazyva® (Obinutuzumab) Injectable Medication Precertification Request
Gilenya® (Fingolimod) Medication Precertification Request
Granix® (tbo-filgrastim) Medicare
Herceptin ® (Trastuzumab), Kadcyla ® (Ado-Trastuzumab) and Perjeta ® (Pertuzumab) Medicare
Ilaris® (Canakinumab) Injectable Medication Precertification Request
Ilumya™ (Tildrakizumab) Medicare
Imfinzi® (Durvalumab) Injectable Medication Precertification Request
Imlygic™ (Talimogene Laherparepvec) Medication Precertification Request
Inflectra® (Infliximab) Medicare
Immune Globulin (IG) Therapy Medicare
Keytruda®(Pembrolizumab) Injectable Medication Precertification Request
Lartruvo™ (Olaratumab) Medication Precertification Request
Lemtrada® (Alemtuzumab) Medicare
Levoleucovorin (Fusilev®, Khapzory™) Injectable Medication Precertification Request
Libtayo® (cemiplimab) Medication Precertification Request
Lucentis® (Ranibizumab) Medicare
Lumoxiti™ (moxetumomab pasudotox)) Medication Precertification Request
Luxturna ® (Voretigene Neparvovec-rzyl) Medication Precertification Request
Macugen® (Pegaptanib Sodium) Injectable Medication Precertification Request
Neulasta® (pegfilgrastim) Medicare
Neupogen® (filgrastim) Medicare
Nivestym™ (filgrastim-aafi) Medicare
Nucala® (Mepolizumab) Injectable Medication Precertification Request
Ocrevus™ (Ocrelizumab) Medication Precertification Request
Onpattro® (patisiran) Injectable Medication Precertification Request
Opdivo® (Nivolumab) Injectable Medication Precertification Request
Orencia® (Abatacept) Medicare
Parsabiv™ (Etelcalcetid) Medication Precertification Request
Prolia®, Xgeva® (Denosumab) Medicare
Provenge Medication Precertification Request
Radicava™ (Edaravone) Medication Precertification Request
Remicade® (Infliximab) Medicare
Pulmonary Arterial Hypertension (Infusible, Inhalation, or Injectable Medication) Medicare
Renflexis® (Infliximab-abda) Medicare
Rituxan® (Rituximab) Medicare
Simponi Aria® (Golimumab) Infusion Medication Precertification Request
Soliris® (Eculizumab) Medication Precertification Request
Spinzara® (Nusinersen) Injectable Precertification Request
Stelara® (Ustekinumab) Medicare
Tecentriq™ (Atezolizumab) Medication Precertification Request
Tegsedi™ (inotersen) Medication Precertification Request
Tremfya® (Guselkumab) Medication Precertification Request
Tysabri® (Natalizumab) Medicare
Udenyca™ (pegfilgrastim-cbqv) Precertification Request
Ultomiris™ (ravulizumab-cwvz) Precertification Request
Vectibix® (Panitumumab) Injectable medication precertification Request
Viscosupplementation Medications Medicare
Xofigo® (Radium-223 dichloride) Injectable Medication Precertification Request
Xolair®(Omalizumab) Medication Precertification
Yervoy® (Ipilimumab) Injectable Medication Precertification Request
Zarxio® (filgrastim-sndz) Medication Precertification Request
National Provider Identifier (NPI)
Network Application Requests
Patient Specific
Pharmacy
Mail Service Order Form (English)
Mail Service Order Form (Spanish)
Prescription Medication Claim (English)
Prescription Medication Claim (Spanish)
Prescription Medication Precertification
Opioid addiction treatment: For Aetna’s commercial plans, there is no precertification required for buprenorphine products.
Part D forms: Please see the Medicare section of this page.
Physician Communications
Practice changes/Provider termination
If your're retiring, moving out of state or changing provider groups, use this form to notify us. We'll need to terminate your existing agreement with us. If your're moving or changing jobs, you can sign a new agreement for your new practice or location.
This form will also update your information on the online provider directory.
Provider termination form and directory update
Specialty Pharmacy Medications
Medication Request (General)
Crohns/Ulcerative Colitis Medication Request
Enzyme Replacement Medication Request
Growth Hormone Medication Request
Hemophilia Medication Request
Hepatitis C Medication Request
HIV Medication Request
Immune Globulin Medication Request
Infertility Medication Request
Multiple Sclerosis Medication Request
Oral Oncology Medication Request
Osteoporosis Medication Request
Psoriasis Medication Request
Rheumatoid/Psoriatic/Juvenile Arthritis and Ankylosing Spondylitis Medication Request
Synagis Medication Request
Synagis® Reorder Form
Transplant Medication Request
Viscosupplementation Medication Request
Vivitrol Reorder Form
Specialty Pharmacy Precertification (Commercial)
Actemra® (Tocilizumab) Precertification Request
ADAKVEO® (crizanlizumab) Medication Precertification Request
Adcetris® (Brentuximab Vedotin) Injectable Medication Precertification Request
Aldurazyme® (laronidase) Medication Precertification Request
Alpha 1 Antitrypsin Inhibitor Therapy Precertification Request
Aranesp® (darbepoetin alfa) Medication Precertification Request
Aveed Medication Precertification Request
Avsola™ (infliximab-axxq) Injectable Medication Precertification Request
Bavencio®(Avelumab) Medication Precertification Request
Benlysta®(Belimumab) Injectable Medication Precertification Request
Beovu® (brolucizumab-dbll) Injectable Medication Precertification Request
Berinert® (C1 esterase inhibitor, human) Medication Precertification Request
Besponsa®(Inotuzumab Ozogamicin) Medication Precertification Request
Brineura® (cerliponase alfa) Medication Precertification Request
Botox® (onabotulinumtoxinA) Injectable Medication Precertification Request
Cerezyme® (imiglucerase) Medication Precertification Request
Cinqair® (Reslizumab) Medication Precertification Request
Cinryze® (C1 esterase inhibitor, human) Medication Precertification Request
Crysvita® (burosumab-twza) Injectable Medication Precertification Request
Cyramza® (Ramucirumab) Medication Precertification Request
Darzalex™ (Daratumumab) Medication Precertification Request
Diabetic Testing Supplies Prior Authorization Request Form
Dysport® (abobotulinumtoxinA) Injectable Medication Precertification Request
Elaprase® (idursulfase) Medication Precertification Request
Elelyso® (taliglucerase alfa) Medication Precertification Request
Empliciti™ (Elotuzumab) Medication Precertification Request
Enhertu® (fam-trastuzumab deruxtecan-nxki) Medication Precertification Request
Entyvio® (Vedolizumab) Injectable Medication Precertification Request
Epogen® -Procrit® -Retacrit™ (epoetin alfa) Medication Precertification Request
Epoprostenol, FLOLAN, VELETRI® (epoprostenol) Medication Precertification Request
Erbitux® (Cetuximab) Injectable medication precertification Request
Exondys51® (Eteplirsen) Injectable Precertification Request
Eylea® (Aflibercept) Injectable Precertification Request
Fabrazyme® (agalsidase beta) Medication Precertification Request
Fasenra™ (Benralizumab) Injectable Medication Precertification Request
Filgrastim Precertification Request (Neupogen®, Granix®, Nivestym®, Zarxio®)
Firazyr® (icatibant injection) Medication Precertification Request
Fulphila™ (pegfilgrastim-jmdb) Medication Precertification Request
Gattex® (Teduglutide) Injectable Medication Precertification Request
GilvaariTM (givosiran) Medication Precertification Request
Granix® (tbo-filgrastim) Medication Precertification Request
Haegarda® (C1 esterase inhibitor, human) Medication Precertification Request
Herceptin® (trastuzumab) Precertification Request
Herceptin Hylecta™ (trastuzumab and hyaluronidase-oysk) Precertification Request
Herzuma™ (trastuzumab-pkrb) Medication Precertification Request
H.P Acthar Gel (Repository Corticotropin) Medication Precertification Request
Imfinzi® (Durvalumab) Injectable Medication Precertification Request
Imlygic™ (Talimogene Laherparepvec) Medication Precertification Request
Immune Globulin (IG) Therapy Medication Precertification Request
Infertility Medication Precertification Request (Female)
Infertility Medication Precertification Request (Male)
Inflectra® (Infliximab) Injectable Medication Precertification Request
Kadcyla® (ado-trastuzumab) Precertification Request
Kalbitor® (ecallantide) Medication Precertification Request
Kanjinti™ (trastuzumab-anns) Precertification Request
Kanuma® (sebelipase alfa) Medication Precertification Request
Keytruda®(Pembrolizumab) Injectable Medication Precertification Request
Lartruvo™ (Olaratumab) Medication Precertification Request
Lemtrada® (Alemtuzumab) Medication Precertification Request
Leukine® (sargramostim) Medication Precertification Request
Levoleucovorin (Fusilev®, Khapzory™) Injectable Medication Precertification Request
Libtayo® (cemiplimab) Medication Precertification Request
Lucentis® (Ranibizumab) Injectable Medication Precertification Request
Lumizyme® (alglucosidase alfa) Medication Precertification Request
Lumoxiti™ (moxetumomab pasudotox)) Medication Precertification Request
Luxturna ® (Voretigene Neparvovec-rzyl) Medication Precertification Request
Macugen® (Pegaptanib Sodium) Injectable Medication Precertification Request
Makena® (Hydroxyprogesterone Caproate) Medication Precertification Request
MEPSEVII™ (vestronidase alfa-vjbk) Medication Precertification Request
Miacalcin® (Calcitonin) Medication Precertification Request
Mircera® (methoxy polyethylene glycol-epoetin beta) Medication Precertification Request
Myalept® (Metreleptin) Injectable Medication Precertification Request
Myobloc® (rimabotulinumtoxinB) Injectable Medication Precertification
Naglazyme® (galsulfase) Medication Precertification Request
Natpara® (rhPTH1-84) Injectable Medication Precertification Request
Neulasta® (pegfilgrastim) Medication Precertification Request
Neupogen® (filgrastim) Medication Precertification Request
Nivestym™ (filgrastim-aafi) Precertification Request
Nucala® (Mepolizumab) Injectable Medication Precertification Request
Ocrevus™ (Ocrelizumab) Medication Precertification Request
Ogivri™ (trastuzumab-dkst) Precertification Request
Onpattro® (patisiran) Injectable Medication Precertification Request
Opdivo® (Nivolumab) Injectable Medication Precertification Request
Orencia® (Abatacept) Precertification Request
Padcev™ (enfortumab vedotin-ejfv) Medication Precertification Request
Parsabiv™ (Etelcalcetid) Medication Precertification Request
Pegfilgrastim Precertification Request (Neulasta®, Fulphila®, Udenyca®, Ziextenzo®)
Perjeta® (pertuzumab) Precertification Request
Polivy Precertification Request
Prolia®, Xgeva® (Denosumab) Medication Precertification Request
Provenge Medication Precertification Request
Radicava™ (Edaravone) Medication Precertification Request
Reblozyl® (luspatercept-aamt) Medication Precertification Request
Remicade® (Infliximab) Precertification Request
Remodulin® (treprostinil) Medication Precertification Request
Renflexis ® (Infliximab-abda) Injectable Medication Precertification Request'
Rituxan® (Rituximab) Precertification Request
Ruconest® (C1 esterase inhibitor, recombinant) Medication Precertification Request
Ruxience™ (rituximab-pvvr) Medication Precertification Request
Sarclisa® (isatuximab-irfc) Medication Precertification Request
Simponi Aria® (Golimumab) Infusion Medication Precertification Request
Soliris® (Eculizumab) Medication Precertification Request
Spinzara® (Nusinersen) Injectable Precertification Request
Spravato™ (esketamine) Medication Precertification Request
Stelara® (Ustekinumab) Precertification Request
Strensiq® (asfotase alfa) Injectable Medication Precertification Request
Synagis® (Palivizumab) Injectable Medication Precertification Request
Takhzyro® (C1 esterase inhibitor, recombinant) Medication Precertification Request
Tecentriq™ (Atezolizumab) Medication Precertification Request
Tegsedi™ (inotersen) Medication Precertification Request
Tepezza™ (teprotumumab-trbw) Medication Precertification Request
Trazimera® (trastuzumab-qyyp) Precertification Request
Truxima™ (rituximab-abbs) Medication Precertification Request
Tysabri® (Natalizumab) Medication Precertification Request
Tyvaso® (treprostinil inhalation solution) Medication Precertification Request
Udenyca™ (pegfilgrastim-cbqv) Precertification Request
Ultomiris™ (ravulizumab-cwvz) Precertification Request
Vectibix® (Panitumumab) Injectable medication precertification Request
Ventavis® (iloprost inhalation solution) Medication Precertification Request
Vimizim® (elosulfase alfa) Medication Precertification Request
Viscosupplementation Injectable Medications Precertification Request
VPRIV® (velaglucerase alfa) Medication Precertification Request
Vyepti™ (eptinezumab-jjmr) Medication Precertification Request
Vyondys 53® (golodirsen) Injectable Medication Precertification Request
Xeomin® (incobotulinumtoxinA) Injectable Medication Precertification Request
Xgeva® (denosumab) Injectable Medication Precertification Request
Xofigo® (Radium-223 dichloride) Injectable Medication Precertification Request
Xolair®(Omalizumab) Medication Precertification
Yervoy® (Ipilimumab) Injectable Medication Precertification Request
Zarxio® (filgrastim-sndz) Medication Precertification Request
Zolgensma Medication Precertification Request
Zulresso™ (brexanolone) Medication Precertification Request
Specialty Medication Precertification Request Form (General)
State Specific
California Prescription Drug Prior Authorization
Colorado Prescription Drug Prior Authorization
Connecticut Accident Detail Questionnaire
Iowa Prescription Drug Prior Authorization
Louisiana Prescription Drug Prior Authorization
Massachusetts Standard Prior Authorization Forms
Michigan Prescription Drug Prior Authorization
New Hampshire Prescription Drug Prior Authorization
New Jersey Appeal a Claim Determination
New Mexico Uniform Prior Authorization
New York Contraceptive Exception Request
Ohio Electronic Funds Transfer (EFT) Opt Out
Oregon Prescription Drug Prior Authorization
Texas Prescription Drug Prior Authorization
Texas Standard Prior Authorization
Texas Telemedicine and Telehealth Services Reimbursement Policy
Washington Intent to Use a Substitute Provider
Washington D.C. Uniform Consultation Referral (Appendix 43-1)