Aetna Specialty Pharmacy®
503 Sunport Lane
Orlando, FL 32809
Infertility Medication Request
Customer Service: 1-866-782-ASRX (1-866-782-2779)
Fax Order Submission: 1-866-FAX-ASRX (1-866-329-2779)
Aetna Specialty Pharmacy will verify benefits and contact members to confirm delivery before medication is shipped.
Today’s Date:
Date Needed:
A. PATIENT INFORMATION
First Name:
Last Name:
Address:
DOB:
City:
Home Phone:
State:
Work Phone:
Weight:
Height:
ZIP:
Cell Phone:
Allergies:
B. INSURANCE INFORMATION
Yes
Does patient have other coverage?
If yes, Carrier Name:
Member ID#:
Insured:
Carrier Name:
Member ID #:
Group #:
Insured:
Medicare:
Yes
No If yes, ID #:
C. PHYSICIAN INFORMATION
Medicaid:
First Name:
Last Name:
Address:
City:
Phone:
Fax:
Yes
No
No
If yes, ID #:
Check one:
M.D.
State:
DEA #:
NPI #:
D.O.
N.P.
ZIP:
Office Contact:
D. DIAGNOSIS
Primary ICD Code:
E. PRESCRIPTION
Other ICD code:
Please refer to the insurance carrier’s participating provider precertification list to verify precertification requirements.
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FOLLISTIM AQ 300 IU Cartridge
FOLLISTIM AQ 600 IU Cartridge
FOLLISTIM AQ 900 IU Cartridge
FOLLISTIM Pen Device
# Vials
# Refills
# Vials
# Refills
ESTRADIOL 0.5mg Tablet
ESTRADIOL 1mg Tablet
ESTRADIOL 2mg Tablet
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# Refills
GONAL F 300 IU Redi-ject
GONAL F 450 IU Redi-ject
GONAL F 900 IU Redi-ject
GONAL F 75 IU Vial
GONAL F 450 IU Vial
GONAL F 1050 IU Vial
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# 1 pen
# Refills
# Refills
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No Refills
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SIG:
SIG:
BRAVELLE 75 IU Vial
SIG:
MENOPUR 75 IU Vial
SIG:
CETROTIDE 0.25mg Kit
SIG:
SIG:
PROMETRIUM 100mg Capsules
PROMETRIUM 200mg Capsules
SIG:
GANIRELIX 250mcg PFS
# PFS
# Refills
SIG:
# Inserts
# Refills
# Boxes
# Refills
# Boxes
# Refills
SIG:
LEUPROLIDE 1mg/0.2ml (2 Week Kit) #Kits
# Refills
SIG:
CRINONE 8% Gel (15/box)
SIG:
PROGESTERONE in SESAME OIL 50mg/ml
10ml Vial
VIVELLE-DOT 0.1MG 8patches/DP
# Vials
# Refills
Qty
# Refills
SIG:
SIG:
(When ordering more than 1 box (8 patches) please call 1-855-240-0535 for max dose override)
Other
SIG:
Qty
Other
# Refills
SIG:
HCG, NOVAREL, PREGNYL, OVIDREL AND CONTROLLED SUBSTANCES
Aetna Specialty Pharmacy is unable to provide HCG, Novarel, Pregnyl,
Ovidrel and controlled substances. Please obtain from another in-network
pharmacy in your area.
COMPOUNDED MEDICATIONS
Please send to CVS Specialty Pharmacy
Phone (877)408-9742 Fax: (866)310-4139
Ship to:
ENDOMETRIN 100mg Vaginal Insert
Physician’s Office
Patient
1 ml syringe
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3 ml syringe
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Insulin Syringes ½ cc #
Other
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Sharps
22g 1-½” needle
25g 1-½” needle
18g 1-½” needle
27g ½” needle
30g ½” needle
Other
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Other address:
Interchange is mandated unless practitioner handwrites the words “MEDICALLY NECESSARY” for each medication.
Prescriber’s Signature (Required by Law):
Aetna Specialty Pharmacy refers to Aetna Specialty Pharmacy, LLC, a subsidiary of Aetna Inc., which is a licensed pharmacy that operates through specialty
pharmacy prescription fulfillment. This pharmacy is a for-profit entity.
GR-68928 (11-16)
P.A.