Prescription Drug Prior Authorization Request Form …

form 61-211 (Revised 12-2016) Effective 7/1/2017 Page 1 of 10 GR-69025-CA (5-17) Fax this form to: 1-877-269-9916 For specialty drugs fax to: 1-888-267-3277 OR Submit your Request online at: CALIFORNIA Prescription DRUG Prior Authorization OR STEP THERAPY EXCEPTION Request FORMPlan/Medical Group Name: _____ Plan/Medical Group Phone#: (_____) Plan/Medical Group Fax#: (_____)_____ Non-Urgent Exigent Circumstances Instructions: Please fill out all applicable sections on both pages completely and legibly. Attach any additional documentation that is important for the review, chart notes or lab data, to support the Prior Authorization or step-therapy exception Request . Information contained in this form is Protected Health Information under HIPAA. Patient Information First Name: Last Name: MI: Phone Number: Address:City:State:Zip Code:Date of Birth: Male Female Circle unit of measure Height (in/cm): _____Weight (lb/kg):_____ Allergies: Patient s Authorized Representative (if applicable): Authorized Representative Phone Number: Insurance Information Primary Insurance Name: Patient ID Number: Secondary Insurance Name: Patient ID Number: Prescriber Information First Name: Last Name: Specialty: Address:City:State:Zip Code:Requestor (if different than prescriber): Office Contact Person: NPI Number (individual): Phone Number: DEA Number (if required): Fax Number (in HIPA)

Form 61-211 (Revised 12-2016) Effective 7/1/2017 Page 3 of 10 GR-69025-CA (5-17) Aetna complies with applicable Federal civil rights …

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