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Collects demographics and insurance information, prescriber and requestor identifiers, medication name and therapy type (new or renewal), dosing, administration route, and dispensing details. Includes sections for prior medication history, diagnoses with ICD-9/ICD-10, required clinical information, attachments, prescriber attestation, HIPAA-relevant confidentiality, and plan-only decision fields (approved/denied).",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/california-aetna-prescription-drug-prior-authorization-request-form/283748/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/california-aetna-prescription-drug-prior-authorization-request-form/283748.png","ImageObject",442,249,{"name":88,"@type":89},"Gloria","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-30","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":30},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"How should the prior authorization request be submitted to Aetna?","Question",{"text":108,"@type":109},"Fax the form to the provided specialty drug or general fax numbers, or submit online via the Navinet link. Fastest service is available by phone during listed business hours.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information is required for the patient section to meet compliance needs?",{"text":113,"@type":109},"The form requires complete patient information, including identifiers and eligibility-related fields, and notes that it must be filled out completely to ensure HIPAA compliance.",{"name":115,"@type":106,"acceptedAnswer":116},"What clinical information must be included to support approval?",{"text":117,"@type":109},"The request must include symptoms, lab results with dates when needed, justification for initial or ongoing therapy or increased dose, contraindications to preferred drugs, and any additional comments or formulary tier exceptions. Attachments such as chart notes or lab data should be included as relevant.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},283748,1790540915,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":30,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},2336474459895,"https://ap-avatar.wpscdn.com/avatar/22000baeef7a5ed0655?x-image-process=image/resize,m_fixed,w_180,h_180&k=1786071322749376916","Fax this form to: 1-877-269-9916  \nFor specialty drugs fax to: 1-888-267-3277 Aetna Specialty Pharmacy phone: 1-866-503-0857 OR Submit your request online at:  \n[https://navinet.navimedix.com/Main.asp](https://navinet.navimedix.com/Main.asp)  \nPRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM For FASTEST service, call 1-855-240-0535, Monday-Friday, [8 a.m. to 6 p.m. Central Time](8 a.m. to 6 p.m. Central Time)  \n\n| Instructions: Please fill out all applicable sections on both pages completely and legibly. Attach any additional documentation that is important for the review, e.g. chart notes or lab data, to support the prior authorization request. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Patient Information: This must be filled out completely to ensure HIPAA compliance |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| First Name: |  |  | Last Name: |  |  |  |  | MI: |  |  | Phone Number: |  |  |  |  |\n| Address: |  |  |  |  | City: |  |  |  |  |  |  | State: |  |  | Zip Code: |\n| Date of Birth: |  Male\u003Cbr> Female |  |  | Circle unit of measure\u003Cbr>Height (in/cm):  Weight (lb/kg):  |  |  |  |  | Allergies: |  |  |  |  |  |  |\n| Patient’s Authorized Representative (if applicable): |  |  |  |  |  |  | Authorized Representative Phone Number: |  |  |  |  |  |  |  |  |\n| Insurance Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Primary Insurance Name: |  |  |  |  |  |  | Patient ID Number: |  |  |  |  |  |  |  |  |\n| Secondary Insurance Name: |  |  |  |  |  |  | Patient ID Number: |  |  |  |  |  |  |  |  |\n| Prescriber Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| First Name: |  |  |  | Last Name: |  |  |  |  |  | Specialty: |  |  |  |  |  |\n| Address: |  |  |  |  |  | City: |  |  |  |  |  | State: |  | Zip Code: |  |\n| Requestor (if different than prescriber): |  |  |  |  |  |  | Office Contact Person: |  |  |  |  |  |  |  |  |\n| NPI Number (individual) : |  |  |  |  |  |  | Phone Number: |  |  |  |  |  |  |  |  |\n| DEA Number (if required): |  |  |  |  |  |  | Fax Number (in HIPAA compliant area): |  |  |  |  |  |  |  |  |\n| Email Address: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Medication / Medical and Dispensing Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Medication Name: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  New Therapy  Renewal\u003Cbr>If Renewal: Date Therapy Initiated: Duration of Therapy (specific dates): |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| How did the patient receive the medication?\u003Cbr> Paid under Insurance Name:  Prior Auth Number (if known):   Other (explain): |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Dose/Strength: |  | Frequency: |  |  |  |  | Length of Therapy/\\#Refills: |  |  |  |  |  | Quantity: |  |  |\n| Administration:\u003Cbr> Oral/SL  Topical  Injection  IV  Other: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Administration Location:\u003Cbr> Physician’s Office\u003Cbr> Ambulatory Infusion Center |  |  Patient’s Home  Long Term Care\u003Cbr> Home Care Agency  Other (explain) : \u003Cbr> Outpatient Hospital Care   |  |  |  |  |  |  |  |  |  |  |  |  |  |\n\nPRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM  \n\n| Patient Name: | ID\\#: |\n| --- | --- |\n\nInstructions: Please fill out all applicable sections on both pages completely and legibly. Attach any additional documentation that is important for the review, e.g. chart notes or lab data, to support the prior authorization request.  \n\n| 1. Has the patient tried any other medications for this condition?  YES (if yes, complete below)  NO |  |  |\n| --- | --- | --- |\n| Medication/Therapy\u003Cbr>(Specify Drug Name and Dosage) | Duration of Therapy\u003Cbr>(Specify Dates) | Response/Reason for Failure/Allergy |\n| 2. List Diagnoses: |  | ICD-9/ICD-10: |\n|  |  |  |\n| 3. Required clinical information-Please provide all relevant clinical information to support a prior authorization review. |  |  |\n| Please provide symptoms","cbCairNwtNe02Ztk","https://ap.wps.com/l/cbCairNwtNe02Ztk","pdf",803066,"English","# Instructions\n## Patient Information\n## Insurance Information\n## Prescriber Information\n## Medication / Medical and Dispensing Information\n## Prior Medication and Diagnoses\n## Required Clinical Information and Attachments\n## Attestation and Signatures\n## Confidentiality Notice\n## Plan Use Only","[{\"question\":\"How should the prior authorization request be submitted to Aetna?\",\"answer\":\"Fax the form to the provided specialty drug or general fax numbers, or submit online via the Navinet link. Fastest service is available by phone during listed business hours.\"},{\"question\":\"What information is required for the patient section to meet compliance needs?\",\"answer\":\"The form requires complete patient information, including identifiers and eligibility-related fields, and notes that it must be filled out completely to ensure HIPAA compliance.\"},{\"question\":\"What clinical information must be included to support approval?\",\"answer\":\"The request must include symptoms, lab results with dates when needed, justification for initial or ongoing therapy or increased dose, contraindications to preferred drugs, and any additional comments or formulary tier exceptions. Attachments such as chart notes or lab data should be included as relevant.\"}]","California-Aetna-Prescription Drug Prior Authorization Request Form | PDF",1789618707]