Prior Authorization Request Form - Brcavantage Page 3

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The following laboratories are contracted with Aetna for the performance of
BRCA testing. All BRCA tests require prior authorization.
Ambry Genetics
Submit completed form with specimen sample to Ambry Genetics, or by fax to 1-949-900-5501.
You may order collection and transportation kits from Ambry Genetics by calling 1-866-262-7943, or
at
Counsyl
Include the completed form and BRCA requisition with the sample. For more information, please call
1-888-COUNSYL (1- 888-268-6795), e-mail or visit
GeneDx, Genpath, Bio-Reference
Submit completed form and blood samples to GeneDx. You may order collection and transportation kits from
GeneDx at 1-888-729-1206 or at
Myriad Genetics Laboratories, Inc.
Submit completed form to Myriad Genetic Laboratories, Inc. with the completed specimen collection kit or
fax to 1-801-584-3615. For questions, please call 1-800-469-7423.
Quest Diagnostics, Inc.
Include completed form with your Quest Diagnostics or affiliate lab requisition and blood sample, or
fax to 1-855-422-5181. Please call BRCAvantage Concierge Services at 1-866-436-3463 or
visit for more information.
This current form should replace all prior Aetna preauthorization forms. For your information, the laboratories became
contracted providers for BRCA services on these effective dates:
Ambry Genetics
currently effective
Counsyl
11/01/2014
GeneDx, Genpath, Bio-Reference
10/15/2014
Myriad Genetics Laboratories, Inc. currently effective
Quest Diagnostics, Inc.
currently effective
GR-67606-4 (10-14)
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