Prior authorization
Aetna Medicare FIDE (HMO D-SNP) requires prior authorization (PA) for some acute outpatient services and planned hospital admissions. Some prescriptions drugs may also require PA. But PA isn’t required for emergency services. You can find the current list of the services that require PA on your secure Provider Portal.
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Tips for requesting authorization
A request for PA is not a guarantee of payment. We won’t reimburse unauthorized services. You can make requesting PA easier for yourself by:
Registering for the Provider Portal, if you haven’t already
Verifying member eligibility before providing services
Checking the coverage for prescription drugs you prescribe on the 2025 Prescription Drug Search tool or by looking at the List of Covered Drugs (Formulary). The criteria for prior authorization and step therapy can be referenced for prescription drug requirements
Attaching supporting documentation when submitting PA requests
Checking services for prior authorization (PDF) requirements
For additional information regarding the Provider Prior Authorization Look up tool, please access the Provider Manual for further details, or call our Provider Experience Team at 1-844-362-0934 (TTY: 711), Monday through Friday, 8 AM to 5PM.
Part B Step Therapy
Under Medicare Advantage plans, some Part B drugs, like injectables or biologics, may have requirements or coverage limits. With step therapy, we require a trial of a preferred drug to treat a medical condition before covering a non-preferred drug.
For example, if drug A and drug B both treat a medical condition, we may prefer drug A and require a trial with it first. If drug A doesn’t work, then we’ll cover drug B.
The step therapy requirement doesn’t apply to patients who’ve already received treatment with the non-preferred drug within the past 365 days.
Find Part B Step Therapy Preferred drugs
You’ll want to use the list of preferred products first. Just check the Part B Step Therapy Preferred Drug lists below for Aetna D-SNP.
Part B Step Therapy
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- Abraxane (albumin-bound paclitaxel) Medicare (PDF)
- Actemra (Tocilizumab) Medicare (PDF)
- Avsola (infliximab-axxq) Injectable Medicare (PDF)
- Beovu (brolucizumab-dbll) Injectable Medicare (PDF)
- Botulinum Toxins Medicare (PDF)
- Entyvio (Vedolizumab) Medicare (PDF)
- Erythropoiesis Stimulating Agents (ESAs) Medications/Dialysis Medicare (PDF)
- Evenity (Romosozumab) Medicare (PDF)
- Eylea (Aflibercept) Medicare (PDF)
- Pegfilgrastim (Fulphila®, Neulasta®, Nyvepria®, Udenyca®, and Ziextenzo®) Medicare (PDF)
- Filgrastim (Granix, Neupogen, Nivestym, Zarxio) Medicare (PDF)
- Herceptin (trastuzumab) Medicare (PDF)
- Ilumya (Tildrakizumab) Medicare (PDF)
- Immune Globulin (IG) Therapy Medicare (PDF)
- Inflectra (Infliximab) Medicare (PDF)
- Lemtrada (Alemtuzumab) Medicare (PDF)
- Lucentis (Ranibizumab) Medicare (PDF)
- Pegfilgrastim (Fulphila®, Neulasta®, Nyvepria®, Udenyca®, and Ziextenzo®) Medicare (PDF)
- Filgrastim (Granix, Neupogen, Nivestym, Zarxio) Medicare (PDF)
- Filgrastim (Granix, Neupogen, Nivestym, Zarxio) Medicare (PDF)
- Pegfilgrastim (Fulphila®, Neulasta®, Nyvepria®, Udenyca®, and Ziextenzo®) Medicare (PDF)
- Orencia (Abatacept) Medicare (PDF)
- Prolia, Xgeva (Denosumab) Medicare (PDF)
- Remicade (Infliximab) Medicare (PDF)
- Pulmonary Arterial Hypertension (Infusible, Inhalation, or Injectable Medication) Medicare (PDF)
- Renflexis (Infliximab-abda) Medicare (PDF)
- Rituxan (Rituximab) Medicare (PDF)
- Simponi Aria (PDF)
- Stelara (Ustekinumab) Medicare (PDF)
- Tysabri (Natalizumab) Medicare (PDF)
- Pegfilgrastim (Fulphila®, Neulasta®, Nyvepria®, Udenyca®, and Ziextenzo®) Medicare (PDF)
- Viscosupplementation Medications Medicare (PDF)
- Filgrastim (Granix, Neupogen, Nivestym, Zarxio) Medicare (PDF)
- Pegfilgrastim (Fulphila®, Neulasta®, Nyvepria®, Udenyca®, and Ziextenzo®) Medicare (PDF)
- Cimzia (Certolizumab Pegol) Medicare (PDF)
- ESA Agents Medicare (PDF)
- Leqvio (Inclisiran) Medicare (PDF)
- Susvimo (Ranibizumab) Medicare (PDF)
- Tremfya (Guselkumab) Medicare (PDF)
- Vabysmo (Faricimab-SVOA) Medicare (PDF)
- Kyprolis (PDF)
- Alpha 1 (PDF)
- Darzalex (PDF)
- Cinqair (PDF)
- Ocrevus (PDF)
- Tremfya (PDF)
- Fasenra (PDF)
- Avastin (PDF)
- Somatuline (PDF)
- Zoladex (PDF)
- Trelstar (PDF)
- Darzalex Faspro (PDF)
- Feraheme (PDF)
- Signifor (PDF)
- Lupron (PDF)
- IVIG (PDF)
How to request PA
Here are the ways you can request PA:
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By phone
You can also request PA by calling 1-844-362-0934 (TTY: 711).
For more information
Check your Provider Manual (PDF). Or call us at 1-844-362-0934 (TTY: 711). We're here from 8 AM to 5 PM, Monday through Friday.