Aetna GR-68988: Prescription Prior Authorization

Prescribers use this general Aetna request for prior authorization, precertification or a medical exception when a prescription medication needs approval under an Aetna commercial plan. It gathers the medication, diagnosis, step therapy history and clinical rationale, with extra questions for certain drug classes. Drug-specific criteria sit in Aetna's Pharmacy Clinical Policy Bulletins rather than separate per-drug forms.

Who completes it

The prescriber completes pages 1 and 2: patient and prescriber information, diagnosis and medication details, any drug-class section, and the signed attestation. Pages 3 to 6 are nondiscrimination and language-assistance notices with nothing to fill in.

How to fill it in

Patient Information and Prescriber Information

Enter today's date, the patient's name, insurance ID number, address, home phone, gender and date of birth. For the prescriber, give the physician's name and address and the office phone and fax numbers. The prescription benefit plan may request additional information or clarification, so give numbers the office monitors.

Diagnosis and Medical Information: medication

List the medication, strength, frequency, quantity, day supply and expected length of therapy. Answer whether it treats a chronic or long-term condition for which it may be necessary for the life of the patient, and for continuation of therapy, how long the patient has been on it. You may instead ask Aetna to fax a drug-specific criteria form, which ends the questions.

Diagnosis and Medical Information: diagnosis and step therapy

State the condition with its ICD code and diagnosis, and whether the patient has a diagnosis of cancer. Because step therapy may be required, list every medication tried for this diagnosis, with therapeutic failure and length of therapy for each drug, any contraindicated drugs, and the adverse event, such as toxicity or allergy, for each drug.

Diagnosis and Medical Information: additional clinical questions

Note whether the patient has a chronic condition, such as a psychiatric condition or diabetes, is stable on the current drug and is at high risk with a change, and name the anticipated adverse event. Add confirming diagnostic tests with dates, pertinent lab values, guideline reasons alternatives are not recommended, required dosage forms, and risk factors such as GI, cardiovascular or age.

Required Clinical Information

Provide all relevant clinical documentation supporting use of the medication. If the drug or class is one listed on page 2 (antiemetic 5-HT3 agents, erectile dysfunction agents, stimulants, Provigil and Nuvigil, testosterones), complete that section. For any other drug or class, attach additional information of no more than two pages. The plan may ask for more information or clarification.

Urgent Request and prescriber attestation

Check Urgent Request only if a standard review timeframe might seriously jeopardize the patient's life or health. The prescriber signs and dates an attestation that the medication is medically necessary, that the information is accurate and true, and that supporting documentation is available to the health plan sponsor or regulators, with a False Claims Act warning.

Erectile Dysfunction and Antiemetic (5-HT3) Agents

For Cialis, Levitra, Viagra or alprostadil, answer whether the patient uses nitrates regularly or intermittently or takes another ED drug, the etiology of erectile dysfunction, and whether the drug is for symptomatic BPH. For 5-HT3 antiemetics, give chemotherapy or radiation frequency, or for hyperemesis gravidarum, inadequate response to two listed drugs such as vitamin B6 or doxylamine.

Topical Testosterones, Provigil/Nuvigil and ADHD Stimulants and Non-Stimulants

For testosterone, confirm two morning fasting levels drawn between 7:00 and 10:00 a.m. on different days, below the lab range or 300 ng/dL, or for low-normal totals, two low free or bioavailable levels. For Provigil or Nuvigil in obstructive sleep apnea, state whether the patient uses CPAP or another device. For ADHD drugs, state whether this is a renewal.

Common mistakes

Attaching more than two pages of additional information for a drug or class not listed on page 2; the form caps attachments at two pages.
Skipping the page 2 section for a listed class such as antiemetic 5-HT3 agents, ED agents, stimulants, Provigil and Nuvigil, or testosterone.
Listing tried medications without the length of therapy for each failure, or without naming the adverse event for each drug, when step therapy may apply.
Sending testosterone levels that were not fasting morning draws taken between 7:00 and 10:00 a.m. on two different days.
Faxing a specialty drug request to the non-specialty line, or the reverse; the form lists separate fax lines for each.
Leaving the prescriber signature and date blank under the attestation on page 2.

Submitting and payment

How to submit it: Fax it to Aetna's non-specialty or specialty drug prior authorization line, whichever matches the drug, or submit the request online through Availity. Aetna lists phone as the fastest route.
Who pays: The prescription benefit plan decides coverage of the medication and may request additional information or clarification to evaluate the request.

Good to know

You can ask Aetna to fax a drug-specific prior authorization criteria form to your office; if you check Yes, the form says no further questions are required.
Plans administered by CVS Caremark use the Caremark form instead. Related Aetna forms include a Medicare Prescription Drug Coverage Determination request, a Tier Exception Request, and state forms for Texas, Illinois and Colorado.
For drugs or classes not covered on page 2, attach additional information, but no more than two pages.
Aetna's forms page notes that buprenorphine products need no precertification under Aetna commercial plans.

Get the official form

Download the current version from the source each time; forms change without notice.

Medical Exception/Prior Authorization/Precertification Request for Prescription Medications

Official page PDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Sources for this guide

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

How do I submit Aetna's prescription prior authorization request?

Fax the completed form to the non-specialty or the specialty drug prior authorization fax line printed at the top, depending on the drug, or submit online through Availity. Aetna describes calling as the fastest service, weekdays during business hours Central Time. The form is revision GR-68988 (11-23).

How do I request an urgent review on the Aetna medication form?

Check the Urgent Request box at the top of page 2, which certifies that applying a standard review timeframe might seriously jeopardize the patient's life or health. Then sign and date the attestation that the medication is medically necessary and the information is accurate, with supporting documentation available on request.

Which drug classes have extra questions on the Aetna form?

Page 2 has sections for erectile dysfunction agents, antiemetic (5-HT3) agents, topical testosterone replacement, Provigil and Nuvigil, and ADHD stimulants and non-stimulants. For any other drug or class, attach additional clinical information, limited to two pages, and check Aetna's Pharmacy Clinical Policy Bulletins for the criteria.

What testosterone labs does the Aetna form ask for?

Two morning fasting total testosterone levels drawn between 7:00 and 10:00 a.m. on different days, below the lab's reference range or below 300 ng/dL. For low-normal totals between 300 and 400 ng/dL, it asks for two low free or bioavailable fasting levels drawn under the same morning conditions.