Get Aetna Gr-69265 2022-2026

Completing the Aetna GR-69265 form is a crucial step in obtaining precertification for ® (aflibercept) injectable medication. This guide provides a clear, step-by-step approach to help users fill out the form accurately and efficiently.

Follow the steps to successfully complete the Aetna GR-69265 form.

1. Press the ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by entering the patient's information in Section A. Include the patient's first name, last name, address, home phone number, current weight, date of birth, city, work phone, cell phone, height, ZIP code, email, and any allergies.
3. In Section B, provide the insurance information by entering the member ID number, group number, and whether the patient has additional coverage. If yes, include the ID number and name of the insurance carrier.
4. Complete Section C with the prescriber’s information. This includes the prescriber's first name, last name, address, phone number, state license number, NPI number, and whether they are an M.D., D.O., N.P., or P.A.
5. Fill out Section D, detailing the dispensing provider/administration information. Indicate the place of administration (e.g., self-administered, physician’s office) and provide the relevant phone number, agency name, and administration codes.
6. In Section E, specify the product information for Aflibercept (), including the dose and directions for use.
7. Complete Section F by providing the primary ICD code and any other applicable ICD codes along with the HCPCS code.
8. Section G requires clinical information. Answer all questions about prior therapy and the patient’s visual acuity, including any contraindications.
9. In Section H, ensure that the request is completed by signing and dating the form.
10. Once all sections are filled out, review the form for accuracy. Users can save changes, download, print, or share the completed form as needed.

Complete your Aetna GR-69265 form online today to ensure proper precertification for your medication.