Pharmacy Authorization Forms

Click "ctrl + f" and type in the name of the drug to search.                                                                           

Common Formulary Prior Authorization Request Form

Aetna's Universal Pharmacy Prior Authorization Fax Form


Biologic Immunomodulators                                                   


Growth Hormones  

Hematopoietic Agents 

Idiopathic Pulmonary Fibrosis

Multiple Sclerosis Agents

Opioids and MME (opioid naive member for more than a 7-day supply of preferred and non-preferred agents) 

Opioids Long-acting and Transdermal (non-preferred agents) 

Opioids Short and Intermediate Acting (non-preferred agents)                                          

Opioid Withdrawal (Lucemyra)  




We are committed to making sure our providers receive the best possible information, and the latest technology and tools available.

We have partnered with CoverMyMeds® and SureScripts to provide you a new way to request a pharmacy prior authorization through the implementation of Electronic Prior Authorization (ePA) program.

With Electronic Prior Authorization (ePA), you can look forward to:

  • Time saving
    • Decreasing paperwork, phone calls and faxes for requests for prior authorization
  • Quicker Determinations
    • Reduces average wait times, resolution often within minutes
  • Accommodating & Secure
    • HIPAA compliant via electronically submitted requests

No cost required! Let us help get you started!

Getting started is easy. Choose ways to enroll:

Billing Information: 

BIN: 610591


Group: RX8826