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Medical Exception / Precertification* Request Form
For Prescription Medications
Please complete form and fax to: 1-800-408-2386 or call 1-800-414-2386.
Visit https://www.aetna.com/provweb/ to register to e-mail your requests for a faster response.
Visit www.aetna.com/formulary to access the Pharmacy Coverage Policy Bulletins.
Physician Signature (REQUIRED)
Please circle Antihistamine requested: ALLEGRA ALLEGRA-D CLARINEX SEMPREX-D ZYRTEC ZYRTEC-D
What is the patient’s diagnosis? (circle all that apply) Allergic Rhinitis Chronic Idiopathic Urticaria Other _____________________
List previous therapy, including OTCs: _______________________________________Dates (if available) __________________________
Response to previous therapy (circle all that apply) Inadequate response Adverse effect(s) Comments ___________________________
Please circle Proton Pump Inhibitor requested: ACIPHEX NEXIUM PREVACID PRILOSEC PROTONIX omeprazole (generic)
What dosage is being requested? _____mg
What is the patient’s diagnosis? (circle all that apply) GERD Nocturnal acid breakthrough Barrett esophagus Hypersecretory condition List previous therapy, with dates: ______________________________________________________________________________________ Response to previous therapy (circle all that apply) Inadequate response Adverse effect(s) Comments __________________________ Please circle COX-II Selective Inhibitor requested:
What is the patient’s diagnosis? (circle all that apply) Osteoarthritis List previous therapy, with dates: _____________________________________________________________________________________ Response to previous therapy (circle all that apply) Inadequate response Adverse effect(s) Comments ___________________________ Does the patient have a history of peptic ulcer disease or NSAID-related ulcer/GI bleeding? Is the patient currently using anticoagulants, antiplatelets, or corticosteroids? Please circle Antifungal requested: DIFLUCAN
What is the patient’s diagnosis? (circle all that apply) Onychomycosis Vulvovaginal Candidiasis Oral Candida (thrush) Candida (esophageal, intestinal, UTI, other) List previous therapy, with dates: _____________________________________________________________________________________
Response to previous therapy (circle all that apply) Inadequate response Adverse effect(s) Comments ___________________________

FOR ONYCHOMYCOSIS: KOH, PAS, fungal culture results: _______ Test Date:__________ Location? Fingernail(s) Toenail(s)
What other conditions does patient have? (circle all that apply) Pain Limiting Activity Diabetes Mellitus Immunosuppression (AIDS, cancer, etc.)
Systemic dermatosis
Peripheral vascular disease Other _______________ If prior onychomycosis therapy, please note: Drug: ________________ Start Date: ___________ Response to previous therapy (circle all that apply) Inadequate response Adverse effect(s) Comments __________________________ Accutane, isotretinoin
What is the patient’s diagnosis? _______________________________________________________________________________________
P revious therapy: (circle all that apply) doxycycline
Other _____________________________________ Response to previous therapy (circle all that apply) Inadequate response Adverse effect(s) Comments ____________________________ If female, pregnancy test results: __________________ Test Date: ______________________________ For ALL other precertification/medical exception requests
Drug requested: ______________________________ Duration of therapy requested: ___________________________________
Diagnosis: __________________________________________________________________________________________________________
Previous therapy(ies) received, with duration: ____________________________________________________________________________
Previous therapy(ies) with inadequate therapeutic response ____________________________________________________________________
Previous therapy(ies) causing adverse effects _______________________________________________________________________________
Therapy(ies) contraindicated in patient ____________________________________________________________________________________
*The term precertification means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company’s clinical criteria for coverage. IT does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO member.

Source: http://www.resourcebenefitsinc.com/forms/AETNA/RXPreApprovalForm.pdf