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Aetna Pharmacy Documents and Forms
Find the documents and forms you need to request specialty medications.
Aetna Specialty Pharmacy offers specialized care for patients with complex chronic conditions.
Aetna Specialty Pharmacy forms
- Cabazitaxel (Jevtana®) Injectable Medication Precertification Request
(PDF, 503 KB) - IVIG therapy medication request form (PDF, 279 KB)
- Multiple Sclerosis medication request form (PDF, 255 KB)
- Crohn's medication request form (PDF, 239 KB)
- General medication request form (PDF)
- HIV/AIDS patient referral/medication request form (PDF)
- EPO/Dialysis medication precertification request form (PDF)
- Provenge medication precertification request form (PDF)
- Rheumatoid Arthritis (Rituxan) medication precertification request form (PDF)
- Repository Corticotropin (H.P Acthar Gel) Injectable medication precertification request form (PDF)
- Cetuximab (Erbitux) Injectable medication precertification request form (PDF)
- Panitumumab (Vectibix) Injectable medication precertification request form (PDF)
- Synagis® statement of medical necessity form (PDF)
- Synagis® reorder form (PDF)
- Infertility drug request form (PDF)
- IVIG therapy medication request form (PDF)
- Crohn’s / Rheumatoid arthritis / Psoriatic arthritis medication request form (PDF)
- Heparin medication request form (PDF)
- Enzyme replacement medication request form (PDF)
- Xolair medication precertification request form (PDF)
- Viscosupplementation medication request form (PDF)
- Oral Oncology medication request form (PDF)
Physician welcome materials
- Physician welcome brochure (PDF)
- Procedure for pharmacies to override point of service edits (PDF)
- Physician satisfaction questionnaire (PDF)
- 2010 Aetna Specialty CareRx expanded drug list
- Most frequently prescribed medications (PDF)
- Infused and injected medications quick guide (PDF)
- 2010 precertification list (PDF)
Tools for Health Care Professionals
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