Form Gr-68285 - Aetha Infertility Injectable Medication Precertification Request Form
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1
2Aetna Precertification Notification
Infertility Injectable Medication
503 Sunport Lane, Orlando, FL 32809
Precertification Request (CPB #0327)
Phone: 1-866-503-0857
FAX:
1-888-267-3277
Page 1 of 2
Please return both pages for precertification of medications.
Please note that authorizations are valid for one cycle only and a request form must be submitted for each cycle.
oday’s date:
T
Please indicate:
Start of treatment
Continuation of therapy, date of last treatment cycle
Date needed:
Ship to:
Doctor’s office
Patient
Other:
Phone:
®
Dispensing Provider:
Aetna Specialty Pharmacy
or
Other:
Phone:
Fax:
TIN:
PIN:
Precertification Requested By:
Phone:
Fax:
A. PATIENT INFORMATION
First Name:
Last Name:
Address:
City:
State:
ZIP:
Home Phone:
Work Phone:
Cell Phone:
DOB:
Allergies:
Email:
Patient Current Weight:
lbs or
kgs
Patient Height:
inches or
cms
Patient Gender:
Female
Male
B. INSURANCE INFORMATION
Aetna Member ID #:
Does patient have other coverage?
Yes
No
Group #:
If yes, provide ID#:
Carrier Name:
Insured:
Insured:
Medicare:
Yes
No
If Yes, provide ID #:
Medicaid:
Yes
No
If Yes, provide ID #:
C. PRESCRIBER INFORMATION
(Circle one):
First Name:
Last Name:
M.D. D.O. N.P. P.A.
Address:
City:
State:
ZIP:
Phone:
Fax:
St Lic #:
NPI #:
DEA #:
UPIN:
Provider Email:
Phone:
Office Contact Name:
(Circle one):
Specialty
Reproductive Endocrinologist
Medical Endocrinologist
Ob/Gyn
Other:
D. DIAGNOSIS INFORMATION
Please indicate type of cycle:
Non-donor IVF cycle
Donor IVF cycle
Frozen Embryo transfer cycle
Ovulation Induction with IUI
Other (please specify)
E. CLINICAL INFORMATION
Yes
No
Has the patient enrolled with Aetna’s Infertility Program (1-800-575-5999) for approval of medical (non-drug) services for
this cycle?
Please indicate whether the patient meets either of the following criteria:
Yes
No
Patient is 35 years of age or younger and has been unable to conceive or produce conception after one
year of frequent unprotected heterosexual intercourse OR without male partner, at least 12 cycles of egg
and sperm contact (e.g., donor insemination).
Yes
No
Patient is over 35 years of age and has been unable to conceive or produce conception after six months
of frequent unprotected heterosexual intercourse OR without male partner, at least 6 cycles of egg and
sperm contact (e.g., donor insemination).
**This medical definition may vary due to state mandates and plan customization.**
Yes
No
Has the patient or patient’s partner had a previous sterilization procedure, with or without surgical reversal, or has the
female undergone a hysterectomy?
Yes
No
Has the patient previously completed any of the following cycles? If Yes, please indicate below the infertility treatments
the patient has previously received:
Yes
No
Injectable Ovulation Stimulation
Yes
No
Non-Donor IVF/GIFT/ZIFT
Yes
No
Donor IVF
**If this is not the first cycle, please provide most current cycle sheet.**
Laboratory criteria:
Please provide the following Lab Values:
Day 3 FSH (serum FSH measured on cycle day 3):
Day 3 Estradiol (E2)
Date:
GR-68285 (12-11)
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