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Aetna Specialty Medication Medical PA Request

Aetna uses this four-page request for precertification of specialty medications covered under the medical benefit, such as provider-administered drugs given in an office, outpatient hospital or home. A prescriber meets it before starting or continuing one of these drugs. Aetna reviews the diagnosis, treatment history and test results, and approvals may carry dosing limits based on FDA labeling, compendia or guidelines.

Who completes it

The prescribing or administering provider completes the form, including the rendering provider, place of service, dispensing pharmacy if different, drug and ICD codes, and the criteria questions. The prescriber or an authorized person signs the attestation.

Submitting and payment

How to submit it
Fax the form with supporting clinical documentation, or submit electronically through Novologix via Availity; Aetna asks for requests at least two weeks before treatment.
Who pays
The form notes that approvals may be subject to dosing limits in accordance with FDA-approved labeling, accepted compendia and evidence-based practice guidelines.

Good to know

  • Medicare Advantage members need Aetna's Medicare fax forms instead of this request.
  • Patient weight and height are required, along with the treatment start date for new requests or the date of last treatment for continuations.
  • Cancer requests ask the disease stage, line of therapy, single or combination use, FDA approval for the setting and NCCN category.
  • Continuation requests ask for documented disease stability or improvement, or, for cancer, evidence of progression or unacceptable toxicity.

Get the official form

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

Specialty Medication Medical Prior Authorization Request

Official pagePDF

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.

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Frequently asked questions

What place of service codes does the Aetna specialty medication form use?

Home (POS 12), outpatient hospital (POS 19 or 22), office (POS 11) or self-administered. If the place of service is not dispensing the drug, the form asks for the dispensing pharmacy's name, NPI and tax ID so Aetna knows who will supply it.

What lab information does the Aetna specialty drug request ask for?

Whether the patient has relevant lab data for the drug, with examples such as complete blood count, liver transaminases, bilirubin, TB testing, pregnancy testing and genetic testing, plus the test names, results and dates. It also asks whether the condition was confirmed by diagnostic testing.