[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-288453-105":3,"detail-sidebar-cat-1-en-105":80,"doc-detail-288453-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":73,"head_meta":75,"extra_data":77,"updated_unix":79},105,"en","medicare-form-specialty-medication-precertification-request","MEDICARE FORM Specialty Medication Precertification Request","","MEDICARE FORM collects required details for specialty medication prior authorization review under Medicare. It instructs providers to complete all fields legibly and routes requests for phone, fax, or electronic prior authorization. The form captures patient demographics, insurance identifiers (Aetna member ID, Medicare/Medicaid status), prescriber and dispensing provider information, product request details (HCPCS, route), primary/secondary diagnosis ICD codes, and required clinical information for precertification decisions.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/medicare-form-specialty-medication-precertification-request/288453/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/medicare-form-specialty-medication-precertification-request/288453.png","ImageObject",442,249,{"name":42,"@type":43},"Mali","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-22","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":30},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"How should specialty medication precertification requests be submitted?","Question",{"text":62,"@type":63},"Submit by phone or fax using the routing table, or consider electronic prior authorization through Availity (use the provided plan-specific links).","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"What patient details are required on the form?",{"text":67,"@type":63},"The form requires patient first and last name, DOB, address, phone numbers, current weight and height, allergies, and other basic demographic fields.",{"name":69,"@type":60,"acceptedAnswer":70},"Which clinical information is needed for precertification review?",{"text":71,"@type":63},"Clinical information must be completed in full for all precertification requests, including whether the patient was treated with other medications for the diagnosis and the previous medication names and treatment date ranges.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},288453,1789978530,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":30,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":30,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":22},2336475104362,"https://ap-avatar.wpscdn.com/avatar/22000c4c46a41b752dd?x-image-process=image/resize,m_fixed,w_180,h_180&k=1786595829695023868","MEDICARE FORM Specialty Medication Precertification Request  \nPage 1 of 3  \n(All fields must be completed and legible for precertification review. )  \nFor Medicare Advantage Part B: For other lines of business:  \nPlease use commercial form.  \nWould you like to use electronic prior authorization? Consider using Availity, our electronic prior authorization portal. Learn more about Availity from the links in the table below.  \nFor phone or fax requests, refer to the table below for routing information. To determine which box to use, refer to the patient’s Aetna ID card. State specific special needs and Medicare-Medicaid Plans may be designated on the front of the ID card or in the website URL on the back of the card. If you don’t see your specific plan listed, call the number on the back of the member’s ID card to confirm routing information.  \n\n| For Aetna Medicare Advantage and Allina Health Aetna Medicare Members send request to: Phone:  1-866-503-0857 (TTY: 711)\u003Cbr>Fax:  1-844-268-7263\u003Cbr>Availity: [https://www.aetna.com/health-care-professionals/resource-center/availity.html](https://www.aetna.com/health-care-professionals/resource-center/availity.html) |\n| --- |\n| For Aetna Medicare FIDE (HMO-DSNP) Virginia Dual Eligible Special Needs Plans send request to: Phone:  1-855-463-0933\u003Cbr>Fax:  1-833-280-5224\u003Cbr>Availity: [https://www.aetnabetterhealth.com/virginia-hmosnp/providers/portal](https://www.aetnabetterhealth.com/virginia-hmosnp/providers/portal) |\n| For Aetna Medicare FIDE (HMO-DSNP) New Jersey Dual Eligible Special Needs Plans send request to: Phone:  1-844-362-0934\u003Cbr>Fax:  1-833-322-0034\u003Cbr>Availity: [https://www.aetnabetterhealth.com/new-jersey-hmosnp/providers/portal.html](https://www.aetnabetterhealth.com/new-jersey-hmosnp/providers/portal.html) |\n| For Aetna Medicare FIDE (HMO D-SNP) Illinois Dual Eligible Special Needs Plans send request to: Phone:  1-866-600-2139\u003Cbr>FAX:  1-855-320-8445\u003Cbr>Availity: [https://www.aetnabetterhealth.com/illinois/providers/portal](https://www.aetnabetterhealth.com/illinois/providers/portal) |\n| For Aetna Medicare HIDE (HMO D-SNP) Michigan Dual Eligible Special Needs Plans send request to: Phone:  1-855-676-5772\u003Cbr>Fax:  1-844-241-2495\u003Cbr>Availity: [https://www.aetnabetterhealth.com/michigan/providers/portal.html](https://www.aetnabetterhealth.com/michigan/providers/portal.html) |\n\nMEDICARE FORM For Medicare Advantage Part B:  \nFor other lines of business:  \nSpecialty Medication Please use commercial form.  \nPrecertification Request  \nPage 2 of 3  \n(All fields must be completed and legible for precertification review. )  \nPlease indicate:  Start of treatment: Start date  / /   \n Continuation of therapy: Date of last treatment  / /   \nPrecertification Requested By:   Phone:   Fax:    \n\n| A. PATIENT INFORMATION |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| First Name: |  |  |  |  | Last Name: |  |  |  |  |  |  |  | DOB: |  |  |\n| Address: |  |  |  |  |  |  | City: |  |  |  |  |  | State: |  | ZIP: |\n| Home Phone: |  |  |  | Work Phone: |  |  | Cell Phone: |  |  |  |  | E-mail: |  |  |  |\n| Current Weight:   lbs or   kgs Height:   inches or   cms |  |  |  |  |  |  |  |  |  | Allergies: |  |  |  |  |  |\n| B. INSURANCE INFORMATION |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Aetna Member ID \\#:   Group \\#:   Insured:   |  |  |  |  |  | Does patient have other coverage?  Yes  No\u003Cbr>If yes, provide ID\\#:   Carrier Name:   Insured:   |  |  |  |  |  |  |  |  |  |\n| Medicare:  Yes  No If yes, provide ID \\#: Medicaid:  Yes  No If yes, provide ID \\#: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| C. PRESCRIBER INFORMATION |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| First Name: |  |  |  |  |  | Last Name: (Check One):  M. D.  D.O.  N. P.  P.A. |  |  |  |  |  |  |  |  |  |\n| Address: |  |  |  |  |  |  |  |  | City: |  |  |  | State: |  ","cbCaiaccNUcNXKmC","https://ap.wps.com/l/cbCaiaccNUcNXKmC","pdf",828922,"English","# Request submission and routing\n## Availity electronic prior authorization\n## Phone and fax routing by plan\n# Form fields\n## Patient information\n## Insurance information\n## Prescriber information\n## Dispensing provider/administration\n## Product and diagnosis information\n## Clinical information requirements","[{\"question\":\"How should specialty medication precertification requests be submitted?\",\"answer\":\"Submit by phone or fax using the routing table, or consider electronic prior authorization through Availity (use the provided plan-specific links).\"},{\"question\":\"What patient details are required on the form?\",\"answer\":\"The form requires patient first and last name, DOB, address, phone numbers, current weight and height, allergies, and other basic demographic fields.\"},{\"question\":\"Which clinical information is needed for precertification review?\",\"answer\":\"Clinical information must be completed in full for all precertification requests, including whether the patient was treated with other medications for the diagnosis and the previous medication names and treatment date ranges.\"}]","MEDICARE FORM Specialty Medication Precertification Request | PDF",1789633499]