Form Gr-68285 - Aetha Infertility Injectable Medication Precertification Request Form Page 2
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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 2 of 2
Please return both pages for precertification of medications.
Patient First Name
Patient Last Name
Patient Phone
Patient DOB
F. PRESCRIPTION
–
To be completed for precertification request. Prescriptions will be forwarded to Aetna Specialty Pharmacy unless otherwise noted.
# of Supp
Follistim AQ (non-preferred)
Endometrin 100 mg
#
300 IU Cartridge
Sig:
#
600 IU Cartridge
* Please note: When ordering more than a quantity of 8 Vivelle Dots,
#
900 IU Cartridge
call 1-800-414-2386 for a max dose override.
Follistim Pen
#
1 pen
*
Vivelle Dot (8/box)
#
75 IU Vial
# of Boxes
0.05 mg
#
150 IU Vial
# of Boxes
0.1 mg
Sig:
Sig:
Gonal-F/Gonal-F RFF (preferred)
Estradiol
#
300 IU Pen
#
0.5 mg Tablet
#
450 IU Pen
#
1 mg Tablet
#
900 IU Pen
#
2 mg Tablet
#
75 IU Vial
Sig:
#
450 IU Vial
Progesterone in Sesame Oil 50mg/ml 10ml Vial
#
1050 IU Vial
# of
Vials
Sig:
Sig:
# of
Vials
Bravelle (preferred) 75 IU
Other:
Sig:
#
# of
Vials
Menopur 75 IU
Sig:
Sig:
COMPOUNDED MEDICATIONS – These will no longer be filled
# of
Vials
Repronex 75 IU
through Aetna Specialty Pharmacy. Prescriptions for compounded
medications will be forwarded to CVS/Caremark at 1-877-408-9742.
Sig:
HCG low dose
Units per
ml
Cetrotide
# of milliliters
# of Refills
0.25 mg Kit
#
3 mg Kit
#
Sig:
Sig:
Lupron Microdose
# of ml
# of Refills
# of
PFS
mcg/0.1ml
Ganirelix 250 mcg
# of ml
# of Refills
mcg/0.2ml
Sig:
Sig:
# of
Vials
Luveris 75 IU
Progesterone Vaginal Suppositories
Sig:
#
# of Refills
100 mg Capsule
# of
Kits
Leuprolide 2 Week Kit
#
# of Refills
200 mg Capsule
Sig:
Sig:
# of
PFS
Ovidrel 250 mcg
Progesterone Vaginal Capsules
Sig:
#
# of Refills
100 mg Capsule
#
# of Refills
Generic HCG, Novarel or Pregnyl 10,000 IU
200 mg Capsule
# of
Vials
Sig:
Sig:
Progesterone Oral Capsules
#
# of Refills
# of
Boxes
100 mg Capsule
Crinone 8% Gel (15/box)
#
# of Refills
200 mg Capsule
Sig:
Sig:
Prometrium
#
Progesterone in
Oil
100 mg Capsule
# of vials
# of Refills
#
50 mg/ml
200 mg Capsule
Sig:
Sig:
SUPPLIES
Methylprednisolone
#
3 ml syringe
#
22g 1-½” needle #
4 mg Tablet
#
27g ½” needle
#
25g 1-½” needle #
8 mg Tablet
#
16 mg Tablet
30g ½” needle
#
18g 1” needle
#
Insulin Syringes ½ cc #
Pen Needle 29G ½” #
Sig:
Other Syringes/Needles
Size
#
* If Aetna Specialty Pharmacy is the dispensing pharmacy, patient benefits will be verified before product is shipped.
* If the prescriber is providing the drug, the provider must verify benefits.
Prescriber’s Signature:
/
/
Date:
(Required by law if Aetna Specialty Pharmacy is the dispensing pharmacy.)
Interchange is mandated unless practitioner writes the words “Brand Medically Necessary” in this space.
GR-68285 (12-11)
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