Forms for health care professionals

It's easy to update a provider address, phone number, fax number or email address, or initiate an out-of-state move or a change in provider group.

Update provider data

ABA Treatment Request (PDF)
Transcranial Magnetic Stimulation (TMS) request (PDF)
Nonparticipating Provider request (PDF)
Florida D-SNP Community Behavioral Health and Targeted Case Management request (Medicaid Primary Services) (PDF)

Coordination of Benefits (PDF)

Provider Dispute Resolution request (PDF)
Provider Dispute Resolution request — California (PDF)
Provider Application to Submit EAP Electronic Claims (PDF)
Statement of Understanding (PDF)

Medicaid providers serving patients with Aetna Better Health insurance coverage must use the process indicated by the health plan they are serving.
 

Find your plan

Autolougous Chondrocyte Implantation Precertification Information Request form (PDF)

Breast and Ovarian Cancer Susceptibility Gene Testing, Prophylactic Mastectomy, and Prophylactic Oophorectomy Precertification Information Request form (PDF)

Breast Reduction and/or Reconstructive Surgery Precertification Information Request form (PDF)

Dorsal Column Stimulator Precertification Information Request form (PDF)

Gender Affirming Surgery Precertification Information Request form (PDF)

Hip Arthroplasty Precertification Form (PDF)

Hip Surgery for Impingement Syndrome Precertification Information Request form (PDF)

Hyperbaric Oxygen Therapy (HBOT) Precertification Information Request form (PDF)

Infertility Services Precertification Information Request form (PDF)

Initial Cochlear Implant Precertification Information Request form (PDF)

Knee Arthroplasty Precertification Form (PDF)

Lower Limb Prosthesis Including Microprocessor-Controlled Knee Precertification Information Request form (PDF)

Obesity Surgery Precertification Information Request form (PDF)

Panniculectomy, Liposuction and Lipectomy Precertification Information Request form (PDF)

Precertification Information Request Form (PDF)

Proton Beam Radiotherapy Precertification Information Request form (PDF)

Ptosis Surgery Precertification Information Request form (PDF)

Shoulder Arthroplasty Precertification Information Request form (PDF)

Sinus Surgery Precertification Information Request form (PDF)

Skilled Home Private Duty Nursing Care Precertification Information Request form (PDF)

Spinal Surgery Precertification Information Request form (PDF)

Uvulopalatopharyngoplasty (UPPP) Precertification Information Request form (PDF)

Varicose Vein Treatment Precertification Information Request form (PDF)

Wheelchairs and Power Operated Vehicles (Scooters) Precertification Information Request form (PDF)

Whole Exome Sequencing (WES) Precertification Information Request form (PDF)

For Part D prior authorization forms, see the Medicare Precertification section or the Medicare medical specialty drug and Part B step therapy precertification section.

Medicare Contracted Practitioner/Provider Complaint and Appeal request (PDF)
Medicare Member Authorization Appeals Process (PDF)
Medicare Member Payment Appeals Process (PDF)
Medicare Non-contracted Provider Appeal Process (PDF)
Medicare Non-contracted Provider Complaint and Appeal Form (PDF)

Standard Organization Determination Information Request Form (PDF)

Hospital Discharge Appeal Notices

Note: This page on the Centers for Medicare & Medicaid Services (CMS) site provides information about patient rights as a hospital inpatient and links to related forms.

Part D prescription drug prior authorizations and exceptions

Medicare Prescription Drug Coverage Determination (PDF)

Topical Testosterone Prior Authorization request (PDF)

Tier Exception (Cost-Share Reduction) Request (PDF)

Request for Medicare Prescription Drug Coverage Determination (PDF)

Abraxane^® (albumin-bound paclitaxel) Injectable Medication Medicare Precertification request (PDF)

Actemra^® (tocilizumab) Injectable Medication Medicare Precertification request (PDF)

Adakveo (crizanlizumbab) Medication Precertification request (PDF)

Adcetris^® (brentuximab vedotin) Injectable Medication Precertification request (PDF)

Aldurazyme® (iaronidase) Medication Precertification request (PDF)

Alpha 1 — Antitrypsin Inhibitor Therapy Medication Precertification request (PDF)

AMONDYS 45™ (casimersen) Injectable Medication Precertification request (PDF)

Avsola (infliximab-axxq) Injectable Medication Precertification request (PDF)

Avastin™ (bevacizumab), Alymsys™ (bevacizumab-maly), Mvasi™ (bevacizumab-awwb), Vegzelma® (bevacizumab-adcd), Zirabev™ (bevacizumab-bvzr) Medication Precertification request (PDF)

Aveed (testosterone undecanoate injection) Medication Precertification request (PDF)

Bavencio^® (Avelumab) Medication Precertification request (PDF)

Bendamustine (Treanda^®, Bendeka^®, Belrapzo^™) Medication Precertification request (PDF)

Benlysta^®(belimumab) Injectable Medication Precertification request (PDF)

Beovu^® (brolucizumab-dbll) Injectable Medication Medicare Precertification request (PDF)

Berinert^® (C1 esterase inhibitor, human) Medication Precertification request (PDF)

Besponsa^®(notuzumab ozogamicin) Medication Precertification request (PDF)

Botulinum Toxins Injectable Medication Medicare Precertification request (PDF)

Brineura^® (cerliponase alfa) Medication Precertification request (PDF)

Byooviz (ranibizumab-nuna) Injectable Medicare Medication Precertification request (PDF)

CAMCEVI (leuprolide) Medication Precertification request (PDF)

Cerezyme^® (imiglucerase) Medication Precertification request (PDF)

Cimerli (ranibizumab-eqrn) Injectable Medicare Medication Precertification request (PDF)

Cimzia^® (certolizumab) Injectable Medication Precertification request (PDF)

Cinqair^® (reslizumab) Medication Precertification request (PDF)

Cinryze^® (C1 esterase inhibitor, human) Medication Precertification request (PDF)

Cosela™ (trilaciclib) Medication Precertification request (PDF)

Crysvita^® (burosumab-twza) Injectable Medication Precertification request (PDF)

Cyramza^® (ramucirumab) Medication Precertification request (PDF)

DANYELZA^® (naxitamab-gqgk) Medication Precertification request (PDF)

Darzalex™ (daratumumab) Medication Precertification request (PDF)

Darzalex Faspro™ (daratumumab and hyaluronidase-fihj) Medication Precertification request (PDF)

Elaprase^® (idursulfase) Medication Precertification request (PDF)

Elelyso^® (taliglucerase alfa) Medication Precertification request (PDF)

Eligard^® (leuprolide acetate suspension for subcutaneous injection) Medication Precertification request (PDF)

Emend^® (fosaprepitant dimeglumine) Injectable Medication Precertification request (PDF)

Empliciti™ (elotuzumab) Medication Precertification request (PDF)

Enhertu^® (fam-trastuzumab deruxtecan-nxki) Medication Precertification request (PDF)

Entyvio (vedolizumab) Injectable Medication Precertification request (PDF)

Erbitux (cetuximab) Injectable Medication Precertification request (PDF)

Erythropoiesis Stimulating Agents Injectable Medication Medicare Precertification request (PDF)

Evenity (romosozumab-aqqg) Injectable Medication Medicare Precertification request (PDF)

Evkeeza™ (evinacumab-dgnb) Medication Precertification request (PDF)

Eylea (aflibercept) Injectable Medication Medicare Precertification request (PDF)

Exondys51^® (eteplirsen) Injectable Medication Precertification request (PDF)

Fabrazyme^® (agalsidase beta) Medication Precertification request (PDF)

Fasenra™ (benralizumab) Injectable Medication Precertification request (PDF)

Feraheme^® (ferumoxytol), Injectafer^® (ferric carboxymaltose) and Monoferric^® (ferric derisomaltose) Medication Precertification request (PDF)

Firmagon^® (degarelix) Medication Precertification request (PDF)

Fulphila™ (pegfilgrastim) Precertification request (PDF)

Fylnetra (pegfilgrastim-pbbk) Medicare Precertification request (PDF)

Gattex^® (teduglutide) Injectable Medication Precertification request (PDF)

Gazyva^® (obinutuzumab) Injectable Medication Precertification request (PDF)

Gilenya^® (fingolimod) Medication Precertification request (PDF)

Gilvaari™ (givosiran) Medication Precertification request (PDF)

Granix^® (tbo-filgrastim) Medicare Precertification request (PDF)

Herceptin ^® (Trastuzumab) Medicare Precertification request (PDF)

Herzuma™ (trastuzumab-pkrb) Medicare Medication Precertification request (PDF)

Herceptin Hylecta™ (trastuzumab and hyaluronidase-oysk) Medicare Precertification request (PDF)

Ilaris^® (canakinumab) Injectable Medication Precertification request (PDF)

Ilumya (tildrakizumab-asmn) Injectable Medication Medicare Precertification request (PDF)

Imfinzi^® (durvalumab) Injectable Medication Precertification request (PDF)

Imlygic™ (talimogene laherparepvec) Medication Precertification request (PDF)

Immune Globulin (IG) Therapy Medication and/or Infusion Medicare Precertification request (PDF)

Inflectra (infliximab-dyyb) Injectable Medication Medicare Precertification request (PDF)

Jelmyto™ (mitomycin) Medication Precertification request (PDF)

JEMPERLI (dostarlimab-gxly) Medication Precertification request (PDF)

Jesduvroq (daprodustat) Medication Precertification request (PDF)

Kadcyla^® (ado-trastuzumab) Medicare Precertification request (PDF)

Kalbitor^® (ecallantide) Medication Precertification request (PDF)

Kanjinti (trastuzumab-anns) Medicare Precertification request (PDF)

Kanuma^® (sebelipase alfa) Medication Precertification request (PDF)

Keytruda^®(pembrolizumab) Injectable Medication Precertification request (PDF)

Kyprolis (carfilzomib) Medication Precertification request (PDF)

Lartruvo™ (olaratumab) Medication Precertification request (PDF)

Leukine^® (sargramostim) Medication Precertification request (PDF)

Lemtrada (alemtuzumab) Medication Medicare Precertification request (PDF)

Leqvio (inclisiran) Injectable Medication Precertification request (PDF)

Levoleucovorin (Fusilev^®, Khapzory™) Injectable Medication Precertification request (PDF)

Libtayo^® (cemiplimab) Medication Precertification request (PDF)

Lucentis (ranibizumab) Injectable Medicare Medication Precertification request (PDF)

Lumizyme^® (alglucosidase alfa) Medication Precertification request (PDF)

Lumoxiti™ (moxetumomab pasudotox) Medication Precertification request (PDF)

Lupron Depot^® (leuprolide acetate for depot suspension) Medication Precertification request (PDF)

Luxturna^® (voretigene neparvovec-rzyl) Injectable Medication Precertification request (PDF)

Macugen (pegaptanib sodium injection) Medication Precertification request (PDF)

Makena^® (hydroxyprogesterone caproate) Injectable Medication Precertification request (PDF)

Mepsevii (vestronidase alfa-vjbk) Medication Precertification request (PDF)

Monjuvi (tafasitamab-cxix) Injectable Medication Precertification request (PDF)

Naglazyme^® (galsulfase) Medication Precertification request (PDF)

Neulasta (pegfilgrastim) Precertification request (PDF)

Neupogen^® (filgrastim) Medicare Precertification request (PDF)

Nivestym™ (filgrastim-aafi) Medicare Precertification request (PDF)

Nucala^® (mepolizumab) Injectable Medication Precertification request (PDF)

Nyvepria (pegfilgrastim-apgf) Medicare Precertification request (PDF)

Nulibry™ (fosdenopterin) Medication Precertification Request (PDF)

Ocrevus^™ (ocrelizumab) Medication Precertification request (PDF)

Ogivri™ (trastuzumab-dkst) Medicare Precertification request (PDF)

Ontruzant^® (trastuzumab-dttb) Medicare Medication Precertification request (PDF)

Onpattro^® (patisiran) Injectable Medication Precertification request (PDF)

Opdivo^® (nivolumab) Injectable Medication Precertification request (PDF)

Orencia^® (abatacept) Injectable Medication Medicare Precertification request (PDF)

Oxlumo™ (lumasiran) Medication Precertification request (PDF)

Padcev™ (enfortumab vedotin-ejfv) Medication Precertification request (PDF)

Parsabiv™ (etelcalcetide) Medication Precertification request (PDF)

Pepaxto® (melphalan flufenamide) Medication Precertification request (PDF)

Perjeta^® (pertuzumab) Medicare Precertification request (PDF)

Phesgo™ (pertuzumab, trastuzumab, and hyaluronidase-zzxf) Medication Precertification request (PDF)

Polivy (polatuzumab vedotin-piig) Medication Precertification request (PDF)

Prolia, Xgeva (denosumab) Injectable Medication Medicare Precertification request (PDF)

Provenge (sipuleucel-T) Injectable Medication Precertification request (PDF)

Pulmonary Hypertension (Inhalation or Injectable Medication) Medicare Precertification request (PDF)

Radicava™ (edaravone) Medication Precertification request (PDF)

Reblozyl (luspatercept-aamt) Medication Precertification request (PDF)

Releuko Injectable Medication Precertification Request (PDF)

Remicade (infliximab) Injectable Medication Medicare Precertification request (PDF)

Renflexis (infliximab-abda) Injectable Medication Medicare Precertification request (PDF)

Riabni® (rituximab-arrx) Medicare (PDF)

Rituxan (rituximab) Medication Medicare Precertification request (PDF)

Rituxan Hycela^® (rituximab and hyaluronidase) Medication Precertification request (PDF)

Rolvedon (eflapegrastim-xnst) Medicare Precertification request (PDF)

Ruconest^® (C1 esterase inhibitor, recombinant) Medication Precertification request (PDF)

Ruxience (rituximab-pvvr) Medication Medicare Precertification request (PDF)

RYBREVANT (amivantamab-vmjw) Medication Precertification request (PDF)

Sandostatin^® (octreotide acetate injection) Medication Precertification request (PDF)

Sarclisa^® (isatuximab-irfc) Medication Precertification request (PDF)

Signifor^® (pasireotide) Medication Precertification request (PDF)

Signifor^® LAR (pasireotide) Medication Precertification request (PDF)

Simponi Aria® (golimumab) Infusion Medication Medicare Precertification request (PDF)

Soliris^® (eculizumab) Medication Precertification request (PDF)

Somatuline Depot^® (lanreotide) Medication Precertification request (PDF)

Somavert^® (pegvisomant) Medication Precertification request (PDF)

Spinzara^® (nusinersen) Injectable Precertification request (PDF)

Spravato™ (esketamine) Medication Precertification request (PDF)

Stelara (ustekinumab) Specialty Medication Medicare Precertification request (PDF)

Stimufend (pegfilgrastim-fpgk) Medicare Precertification request (PDF)

Strensiq^® (asfotase alfa) Injectable Medication Precertification request (PDF)

Susvimo (ranibizumab) Injectable Medication Precertification request (PDF)

Synagis^® (Palivizumab) Injectable Medication Precertification request (PDF)

Takhzyro^® (C1 esterase inhibitor, recombinant) Medication Precertification request (PDF)

Tecentriq™ (Atezolizumab) Medication Precertification request (PDF)

Tegsedi™ (inotersen) Medication Precertification request (PDF)

Tepezza™ (teprotumumab-trbw) Medication Precertification request (PDF)

Trazimera^® (trastuzumab-qyyp) Medicare Precertification request (PDF)

Trelstar^® (triptorelin pamoate) Medication Precertification request (PDF)

Trodelvy^™ (sacituzumab govitecan-hziy) Medication Precertification request (PDF)

Truxima (rituximab-abbs) Medication Medicare Precertification request (PDF)

Tysabri (natalizumab) Medication Medicare Precertification request (PDF)

Udenyca™ (pegfilgrastim-cbqv) Precertification request (PDF)

Ultomiris™ (ravulizumab-cwvz) Precertification request (PDF)

Uplizna™ (inebilizumab-cdon) Medication Precertification request (PDF)

Vabysmo (faricimab-svoa) Injectable Medication Precertification request (PDF)

Vectibix^® (panitumumab) Injectable Medication Precertification request (PDF)

Viltepso™ (viltolarsen) Medication Precertification request (PDF)

Vimizim^® (elosulfase alfa) Medication Precertification request (PDF)

Viscosupplementation Injectable Medication Medicare Precertification request (PDF)

Vpriv (velaglucerase alfa) Medication Precertification request (PDF)

Vyepti™ (eptinezumab-jjmr) Medication Precertification request (PDF)

Vyondys 53^® (golodirsen) Injectable Medication Precertification request (PDF)

Xofigo (radium RA 223 dichloride) Injectable Medication Precertification request (PDF)

Xolair(omalizumab) Injectable Medication Precertification request (PDF)

Yervoy^® (ipilimumab) Injectable Medication Precertification request (PDF)

Zarxio^® (filgrastim) Medication Precertification request (PDF)

Ziextenzo (pegfilgrastim-bmez) Medication Medicare Precertification request (PDF)

Zoladex^® (goserelin acetate) Medication Precertification request (PDF)

Zolgensma (onasemnogene abeparvovec-xioi) Medication Precertification request (PDF)

Zulresso™ (brexanolone) Medication Precertification request (PDF)

Zynlonta (loncastuximab tesirine-lpyl) Medication Precertification request (PDF)

NPI Submissions form
NPI Exemption Notification form

Medical Request for Participation form
Request to join the Aetna Dental network instructions
Behavioral Health Provider Application request
Facility request to join the Aetna network
Join the Pharmacy Network application request
Join the First Health Network request

Authorized Representative request (PDF)
Member Complaint and Appeal form (PDF)
Practitioner and Provider Complaint and Appeal request (PDF)

Medicaid providers serving patients with Aetna Better Health insurance coverage must use the process indicated by the health plan they are serving.
 

Find your plan

Oral Surgery Precertification Request (PDF)

Orthognathic Surgery Precertification Request (PDF)

Sleep Apnea Appliance Precertification Information Request (PDF)

TMJ Treatment Precertification Information Request (PDF)

Infertility Program Patient Registration form (PDF)

Mail Service Order form — English (PDF)
Mail Service Order form — Spanish (PDF)

Commercial Prescription Drug Claim form — English (PDF)

Commercial Prescription Drug Claim form — Spanish (PDF)

Prescription Medication Medical Exception/Precertification request (PDF)

Opioid addiction treatment: For Aetna commercial plans, there is no precertification required for buprenorphine products.

Part D forms: Please see the Medicare section of this page.

Colorado contraceptives exception form (PDF)

Colorado step therapy protocol exception process (PDF)

Maryland step therapy protocol exception process (PDF)

Nevada step therapy protocol exception process (PDF)

Diabetes Visit Assessment Tool (PDF)

Dilated Retinal Eye Exam (PDF)

Pediatric Vaccine Record (PDF)

Physician Communication form (PDF)

Post-Fragility Fracture Care form (PDF)

Specialist Consultant Report (PDF)

If you’re retiring, moving out of state or changing provider groups, simply use this form to let us know so we can terminate your existing agreement with us. If you’re moving or changing jobs, you can sign a new agreement for your new practice or location.

Note: This form will also update your information on our online provider directory.

Provider Termination request

Actemra (tocilizumab) IV Medication Precertification request (PDF)

Aduhelm™ (aducanumab-avwa) Medication Precertification request (PDF)

Adakveo (crizanlizumab) Medication Precertification request (PDF)

Adcetris (brentuximab vedotin) Injectable Medication Precertification request (PDF)

Adstiladrin® (nadofaragene firadenovec-vncg) Medication Precertification request (PDF)

Adzynma (ADAMTS13, recombinant-krhn) Medication Precertification request (PDF)

Aldurazyme (Iaronidase) Medication Precertification request (PDF)

Alpha 1 – Proteinase Inhibitors Medication Precertification request (PDF)

AMONDYS 45 (casimersen) Injectable Medication Precertification request (PDF)

Amvuttra™ (vutrisiran) Injectable Medication Precertification request (PDF)

Anktiva® (nogapendekin alfa inbakicept-pmln) Medication Precertification request (PDF)

Aranesp (darbepoetin alfa) Medication Precertification request (PDF)

Avastin (bevacizumab), Mvasi (bevacizumab-awwb), Zirabev (bevacizumab-bvzr) Medication Precertification request (PDF)

Aveed (testosterone undecanoate injection) Medication Precertification request (PDF)

Avsola (infliximab-axxq) Injectable Medication Precertification request (PDF)

Bavencio (avelumab) Injectable Medication Precertification request (PDF)

Bendamustine (Treanda®, Bendeka®, Belrapzo®, Vivimusta™) Medication Precertification request (PDF)

Benlysta (belimumab) Injectable Medication Precertification request (PDF)

Beovu (brolucizumab-dbll) Injectable Medication Precertification request (PDF)

Beqvez™ (fidanacogene elaparvovec-dzkt) Medication Precertification request (PDF)

Berinert (C1 esterase inhibitor, human) Medication Precertification request (PDF)

Besponsa (inotuzumab ozogamicin) Medication Precertification request (PDF)

Blenrep (belantamab mafodotin-blmf) Medication Precertification request (PDF)

Brineura (cerliponase alfa) Medication Precertification request (PDF)

Briumvi™ (ublituximab-xiiy) Medication Precertification request (PDF)

bortezomib-Velcade Medication Precertification request (PDF)

Botox (onabotulinumtoxinA) Injectable Medication Precertification request (PDF)

CAMCEVI (leuprolide) Medication Precertification request (PDF)

Casgevy™ (exagamglogene autotemcel) Medication Precertification request (PDF)

Cerezyme (imiglucerase) Medication Precertification request (PDF)

Cimzia (certolizumab) Injectable Medication Precertification request (PDF)

Cinqair (reslizumab) Medication Precertification request (PDF)

Cinryze (C1 esterase inhibitor, human) Medication Precertification request (PDF)

Cosela (trilaciclib) Medication Precertification request (PDF)

Cosentyx® (secukinumab) Injectable Medication Precertification request (PDF)

Crysvita (burosumab-twza) Injectable Medication Precertification request (PDF)

Cyramza (ramucirumab) Medication Precertification request (PDF)

DANYELZA (naxitamab-gqgk) Medication Precertification request (PDF)

Darzalex (daratumumab) Medication Precertification request (PDF)

Darzalex Faspro (daratumumab and hyaluronidase-fihj) Medication Precertification request (PDF)

Daxxify® (daxibotulinumtoxinA-lanm) Medication Precertification request (PDF)

Diabetic Testing Supplies Prior Authorization request Form (PDF)

Dysport (abobotulinumtoxinA) Injectable Medication Precertification request (PDF)

ELAHERE™ (mirvetuximab soravtansine-gynx) Injectable Medication Precertification request (PDF)

Elaprase (idursulfase) Medication Precertification request (PDF)

Elelyso (taliglucerase alfa) Medication Precertification request (PDF)

Elevidys (delandistrogene moxeparvovec-rokl) Medication Precertification request (PDF)

Elfabrio® (pegunigalsidase alfa-iwxj) Medication Precertification request (PDF)

Eligard (leuprolide acetate suspension) Medication Precertification request (PDF)

ELREXFIO® (elranatamab-bcmm) Medication Precertification request (PDF)

Empliciti (elotuzumab) Medication Precertification request (PDF)

Enhertu (fam-trastuzumab deruxtecan-nxki) Medication Precertification request (PDF)

Enjaymo™ (sutimlimab-jome) Medication Precertification request (PDF)

Entyvio (vedolizumab) Injectable Medication Precertification request (PDF)

EPKINLY™ (epcoritamab-bysp) Medication Precertification request (PDF)

Epogen-Procrit-Retacrit (epoetin alfa) Medication Precertification request (PDF)

Epoprostenol, Flolan, Veletri (epoprostenol) Medication Precertification request (PDF)

Erbitux (cetuximab) Injectable Medication Precertification request (PDF)

Evkeeza (evinacumab-dgnb) Medication Precertification request (PDF)

Evrysdi (risdiplam) Medication Precertification request (PDF)

Exondys51 (eteplirsen) Injectable Precertification request (PDF)

Eylea®-Eylea® HD (aflibercept) Injectable Medication Precertification request (PDF)

Fabrazyme (agalsidase beta) Medication Precertification request (PDF)

Fasenra (benralizumab) Injectable Medication Precertification request (PDF)

Feraheme (ferumoxytol) and Injectafer (ferric carboxymaltose) Medication Precertification request (PDF)

Filgrastim (Neupogen, Granix, Nivestym, Zarxio) Medication Precertification request (PDF)

Firazyr - Sajazir (icatibant injection) Medication Precertification request (PDF)

Firmagon (degarelix) Medication Precertification request (PDF)

FYARRO™ (sirolimus protein-bound particles for injectable suspension) (albumin-bound) Medication Precertification request (PDF)

Gattex (teduglutide) Injectable Medication Precertification request (PDF)

Gilvaari (givosiran) Medication Precertification request (PDF)

Haegarda (C1 esterase inhibitor, human) Medication Precertification request (PDF)

Hemgenix® (etranacogene dezaparvovec-drlb) Medication Precertification request (PDF)

Herceptin and Trastuzumab Biosimilars Precertification request (PDF)

Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) Precertification request (PDF)

Acthar® Gel (repository corticotropin), Purified Cortrophin™ Gel (repository corticotropin) Injectable Medication Precertification request (PDF)

Hyaluronates (viscosupplementation) Injectable Medication Precertification request (PDF)

Ilumya® (tildrakizumab-asmn) Medication Precertification request (PDF)

Imdelltra™ (tarlatamab-dlle) Medication Precertification request (PDF)

Imfinzi (durvalumab) Injectable Medication Precertification request (PDF)

IMJUDO® (tremelimumab) Injectable Medication Precertification request (PDF)

Imlygic (talimogene laherparepvec) Medication Precertification request (PDF)

Immune Globulin (IG) Therapy Medication and/or Infusion Precertification request (PDF)

Infertility (Female) Injectable Medication Precertification request (PDF)

Infertility (Male) Injectable Medication Precertification request (PDF)

Inflectra (infliximab-dyybb) Injectable Medication Precertification request (PDF)

Izervay™ (avacincaptad pegol) Medication Precertification request (PDF)

Jelmyto (mitomycin) Medication Precertification request (PDF)

JEMPERLI (dostarlimab-gxly) Medication Precertification request (PDF)

Kadcyla (ado-trastuzumab) Precertification request (PDF)

Kalbitor (ecallantide) Medication Precertification request (PDF)

Kanuma (sebelipase alfa) Medication Precertification request (PDF)

Keytruda (pembrolizumab) Injectable Medication Precertification request (PDF)

KIMMTRAK® (tebentafusp-tebn) Injectable Medication Precertification request (PDF)

Korsuva® (difelikefalin injection) Medication Precertification request (PDF)

Kyprolis (carfilzomib) Medication Precertification request (PDF)

Lamzede® (velmanase alfa-tycv) Medication Precertification request (PDF)

Lartruvo (olaratumab) Medication Precertification request (PDF)

Lemtrada (alemtuzumab) Medication Precertification request (PDF)

Leqembi™ (lecanemab-irmb) Medication Precertification request (PDF)

Leqvio® (inclisiran) Medication Precertification request (PDF)

Leukine (sargramostim) Medication Precertification request (PDF)

Levoleucovorin (Fusilev, Khapzory) Injectable Medication Precertification request (PDF)

Libtayo (cemiplimab) Medication Precertification request (PDF)

Loqtorzi™ (toripalimab-tpzi) Medication Precertification request (PDF)

Lucentis® (ranibizumab), Byooviz™ (ranibizumab), Cimerli™ (ranibizumab-eqrn) Injectable Medication Precertification request (PDF)

Lumizyme (alglucosidase alfa) Medication Precertification request (PDF)

Lumoxiti (moxetumomab pasudotox)) Medication Precertification request (PDF)

LUNSUMIO™ (mosunetuzumab-axgb) Medication Precertification request (PDF)

Lupron Depot (leuprolide acetate for depot suspension) Medication Precertification request (PDF)

Lupron Depot-PED (leuprolide acetate for depot suspension) Medication Precertification request (PDF)

LUTATHERA® (lutetium Lu 177 dotatate) Medication Precertification request (PDF)

Luxturna (voretigene neparvovec-rzyl) Medication Precertification request (PDF)

Macugen (pegaptanib sodium) Injectable Medication Precertification request (PDF)

MARGENZA™ (margetuximab-cmkb) Medication Precertification request (PDF)

Makena (hydroxyprogesterone caproate) Medication Precertification request (PDF)

Mepsevii (vestronidase alfa-vjbk) Medication Precertification request (PDF)

Mircera (methoxy polyethylene glycol-epoetin beta) Medication Precertification request (PDF)

Monjuvi (tafasitamab-cxix) Injectable Medication Precertification request (PDF)

Myalept (metreleptin) Injectable Medication Precertification request (PDF)

Myobloc (rimabotulinumtoxinB) Injectable Medication Precertification request (PDF)

Naglazyme (galsulfase) Medication Precertification request (PDF)

Natpara (parathyroid hormone) Medication Precertification request (PDF)

Nexviazyme (avalglucosidase alfa-ngpt) Medication Precertification request (PDF)

Nucala (mepolizumab) Injectable Medication Precertification request (PDF)

Nulibry (fosdenopterin) Medication Precertification request (PDF)

Ocrevus (ocrelizumab) Medication Precertification request (PDF)

Octreoti de acetate injection, Sandostatin, Sandostatin, LAR Depot or Bynfezia Pen Medication Precertification request (PDF)

OMISIRGE® (omidubicel-onlv) Medication Precertification request (PDF)

Omvoh™ (mirikizumab-mrkz) Medication Precertification request (PDF)

Onpattro (patisiran) Injectable Medication Precertification request (PDF)

Opdivo (nivolumab) Injectable Medication Precertification request (PDF)

Opdualag™ (nivolumab and relatlimab-rmbw) Medication Precertification request (PDF)

Orencia (abatacept) IV Precertification request (PDF)

Oxlumo (lumasiran) Medication Precertification request (PDF)

Padcev (enfortumab vedotin-ejfv) Medication Precertification request (PDF)

Parsabiv (etelcalcetide) Medication Precertification request (PDF)

PEDMARK® (sodium thiosulfate) Medication Precertification request (PDF)

Pegfilgrastim Precertification request (Neulasta®, Fulphila®, Fylnetra® , Nyvepria™, Stimufend®, Udenyca®, Ziextenzo®) (PDF)

Perjeta (pertuzumab) Precertification request (PDF)

Pepaxto (melphalan flufenamide) Medication Precertification request (PDF)

Phesgo (pertuzumab, trastuzumab, and hyaluronidase-zzxf) Medication Precertification request (PDF)

PLUVICTO® (lutetium Lu 177 vipivotide tetraxetan) Medication Precertification request (PDF)

Polivy (polatuzumab vedotin-piig) Medication Precertification request (PDF)

Prolia® (denosumab) Injectable Medication Precertification request (PDF)

Provenge (sipuleucel-T) Injectable Medication Precertification request (PDF)

Qalsody™ (tofersen) Medication Precertification request (PDF)

Radicava (edaravone) Medication Precertification request (PDF)

Reblozyl (luspatercept-aamt) Medication Precertification request (PDF)

Remicade (infliximab) Injectable Precertification request (PDF)

Remodulin (treprostinil) Medication Precertification request (PDF)

Renflexis (infliximab-abda) Injectable Medication Precertification request (PDF)

Rituxan Hycela (rituximab and hyaluronidase) Medication Precertification request (PDF)

Rituxan® and Rituximab Biosimilars Precertification request (PDF)

Rivfloza™ (nedosiran) Medication Precertification request (PDF)

Roctavian™ (valoctocogene roxaparvovec-rvox) Medication Precertification request (PDF)

Rolvedon™ (eflapegrastim-xnst) Medication Precertification request (PDF)

Ruconest (C1 esterase inhibitor, recombinant) Medication Precertification request (PDF)

RYBREVANT (amivantamab-vmjw) Medication Precertification request (PDF)

Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) Medication Precertification request (PDF)

Ryplazim (plasminogen, human-tvmh) Medication Precertification request (PDF)

Rystiggo® (rozanolixizumab-noli) Medication Precertification request (PDF)

Ryzneuta™ (efbemalenograstim alfa-vuxw) Medication Precertification request (PDF)

Saphnelo™ (anifrolumab-fnia) Injectable Medication Precertification request (PDF)

Sarclisa (isatuximab-irfc) Medication Precertification request (PDF)

Signifor (pasireotide) Medication Precertification request (PDF)

Signifor LAR (pasireotide) Medication Precertification request (PDF)

Simponi Aria (golimumab) Infusion Medication Precertification request (PDF)

Skyrizi® (risankizumab-rzaa) Medication Precertification request (PDF)

Skysona® (elivaldogene autotemcel) Medication Precertification request (PDF)

Soliris (eculizumab) Injectable Medication Precertification request (PDF)

Somatuline Depot (lanreotide) Medication Precertification request (PDF)

Somavert (pegvisomant) Medication Precertification request (PDF)

Spevigo® (spesolimab-sbzo) Medication Precertification request (PDF)

Spinraza (nusinersen) Injectable Precertification request (PDF)

Spravato (esketamine) Medication Precertification request (PDF)

Stelara (ustekinumab) IV Specialty Medication Precertification request (PDF)

Strensiq (asfotase alfa) Injectable Medication Precertification request (PDF)

Strontium Chloride Sr-89 (METASTRON™) Medication Precertification request (PDF)

SUSVIMO (ranibizumab) Injectable Medication Precertification request (PDF)

Syfovre® (pegcetacoplan) Medication Precertification request (PDF)

Synagis (palivizumab) Injectable Medication Precertification request (PDF)

Takhzyro (C1 esterase inhibitor, recombinant) Medication Precertification request (PDF)

Talvey® (talquetamab-tgvs) Medication Precertification request (PDF)

Tecentriq (atezolizumab) Medication Precertification request (PDF)

Tegsedi (inotersen) Medication Precertification request (PDF)

TECVAYLI™ (teclistamab-cqyv) Medication Precertification request (PDF)

Tepezza (teprotumumab-trbw) Medication Precertification request (PDF)

Tezspire™ (tezepelumab-ekko) Medication Precertification request (PDF)

TIVDAK (tisotumab vedotin-tftv) Medication Precertification request (PDF)

Trelstar (triptorelin pamoate) Medication Precertification request (PDF)

Trodelvy (sacituzumab govitecan-hziy) Medication Precertification request (PDF)

Tysabri (natalizumab) Medication Precertification request (PDF)

Tyvaso (treprostinil inhalation solution) Medication Precertification request (PDF)

Tzield™ (teplizumab-mzwv) Medication Precertification request (PDF)

Ultomiris (ravulizumab-cwvz) Precertification request (PDF)

Uplizna (inebilizumab-cdon) Medication Precertification request (PDF)

VABYSMO™ (faricimab-svoa) Injectable Medication Precertification request (PDF)

Vectibix (panitumumab) Injectable Medication Precertification request (PDF)

VEOPOZ™ (pozelimab-bbfg) Medication Precertification request (PDF)

Viltepso (viltolarsen) Medication Precertification request (PDF)

Ventavis (iloprost inhalation solution) Medication Precertification request (PDF)

Vimizim (elosulfase alfa) Medication Precertification request (PDF)

Vpriv (velaglucerase alfa) Medication Precertification request (PDF)

Vyepti (eptinezumab-jjmr) Medication Precertification request (PDF)

Vyjuvek™ (beremagene geperpavec-svdt) Medication Precertification request (PDF)

Vyondys 53 (golodirsen) Injectable Medication Precertification request (PDF)

Vyvgart® (efgartigimod alfa-fcab), Vyvgart® Hytrulo (efgartigiomod alfa and hyaluronidase-qvfc) Medication Precertification request (PDF)

Wainua™ (eplontersen) Medication Precertification request (PDF)

Winrevair™ (sotatercept-csrk) Medication Precertification request (PDF)

Xenpozyme™ (olipudase alfa-rpcp) Medication Precertification request (PDF)

Xeomin (incobotulinumtoxinA) Injectable Medication Precertification request (PDF)

Xgeva (denosumab) Injectable Medication Precertification request (PDF)

Xofigo (radium RA 223 dichloride) Injectable Medication Precertification request (PDF)

Xolair (omalizumab) Medication Precertification request (PDF)

Yervoy (ipilimumab) Injectable Medication Precertification request (PDF)

Zoladex (goserelin acetate) Medication Precertification request (PDF)

Zolgensma (onasemnogene abeparvovec-xioi) Medication Precertification request (PDF)

Zulresso (brexanolone) Medication Precertification request (PDF)

Zynlonta (loncastuximab tesirine-lpyl) Medication Precertification request (PDF)

Zynyz™ (retifanlimab-dlwr) Injectable Medication Precertification request (PDF)

Specialty Medication Precertification request (PDF)

General forms

Arizona Standard Prior Authorization requests (PDF)

Connecticut Accident Detail Questionnaire (PDF)

Hawaii Notice of Non-Disclosure of Minor Mental Health Care (PDF)

Massachusetts Standard Prior Authorization forms

Nevada Step Therapy Prior Authorization form (PDF)

New Jersey Claims Determination Appeal application (PDF)

New Mexico Prior Authorization request (PDF)

Ohio Electronic Funds Transfer (EFT) Opt Out request (PDF)

Texas Standard Prior Authorization, Health Care Services request (PDF)

Texas Telemedicine and Telehealth Services Reimbursement Policy (PDF)

Washington Intent to Use a Substitute Provider (PDF)

Washington D.C. Uniform Consultation Referral

Prescription drug forms

Arizona Prescription Drug Prior Authorization request (PDF)

California Prescription Drug Prior Authorization request (PDF)

Colorado Prescription Drug Prior Authorization request (PDF)

Illinois Prior Authorization request (PDF)

Iowa Prescription Drug Prior Authorization request (PDF)

Louisiana Prescription Drug Prior Authorization request (PDF)

Michigan providers: New electronic prior authorization law

Michigan amended its current utilization review law. Starting June 1, 2023, all prior authorization requests need to be submitted electronically. It’s easy to work with us on Availity. It will help you stay compliant and you can take advantage of many other benefits. To register for Availity, you’ll need your physical address, billing address, tax ID, NPI and primary specialty. Already registered? Log in to Availity.

Michigan Prescription Drug Prior Authorization request (PDF)

New Hampshire Prescription Drug Prior Authorization request (PDF)

New York Contraceptive Exception request (PDF)

Oregon Prescription Drug Prior Authorization, Medical Exception request (PDF)

Texas Prescription Drug Prior Authorization request (PDF)

Business check forgery statement (PDF)

Individual check forgery statement (PDF)

Foreign business check forgery statement (PDF)

Foreign individual check forgery statement (PDF)

Business check forgery alteration (PDF)

Individual check forgery alteration (PDF)