Get Aetna C12381-a 2019-2025

The Aetna C12381-A form is essential for submitting prior authorization requests for medications. This guide will provide you with a comprehensive approach to accurately completing this form online, ensuring all necessary information is provided.

Follow the steps to fill out the Aetna C12381-A form effectively.

1. Click the ‘Get Form’ button to obtain the form and open it in your document editor.
2. Begin by entering the member's information in the designated fields. This includes the member's full name, date of birth, and member ID, as well as their city and state.
3. Provide the prescribing provider's information. Fill in the provider's full name, specialty, NPI number, DEA number, and complete office address, including the city, state, and zip code.
4. Complete the dispensing pharmacy information, including the pharmacy name and both the pharmacy phone and fax numbers.
5. In the requested medication information section, specify if the medication request is for an FDA-approved or compendia-supported diagnosis by circling 'Yes' or 'No'. Then, state the diagnosis and corresponding ICD-10 code.
6. Indicate any contraindications to formulary medications, specify the strength of the medication, and detail directions for use, quantity, and dosage form, as well as the duration of therapy.
7. Select either a new request or continuation of therapy request, and provide information about any medications the member has previously attempted and failed to use for the diagnosis.
8. Choose the turnaround time for review by selecting either ‘Standard’ or ‘Urgent’ based on the member's needs.
9. Proceed to fill in the clinical information related to the specific conditions such as atopic dermatitis, asthma, and chronic rhinosinusitis, answering each question as required.
10. Finally, add any additional information pertinent to the request that the prescribing provider feels is necessary and ensure the provider's signature, along with the date, is included.
11. Once all sections are completed, you can save your changes, download the form, print it, or share it as required.

Complete your Aetna C12381-A form online to ensure timely processing of your prior authorization request.