Aetna prior authorization and CPT code lookup, page 16
CPT code lookup
Each row is one code from the participating-provider precertification list. This is not a coding dictionary, and it is not a coverage decision. The description is the service name on that list.
Participating-provider outpatient list
Inpatient, emergency, and observation settings are outside this outpatient list. This page does not publish a determination for those settings.
Prior authorization codes
| Code | Description | Source |
|---|---|---|
| C9312 | Evdi (trabectedin) — precertification required effective August 1, 2026 | Participating provider precertification list for Aetna, Pg 23 Original policy |
| J1305 | Evkeeza (evinacumab-dgnb) — precertification required for the drug and site of care | Participating provider precertification list for Aetna, Pg 23 Original policy |
| J2916 | Ferrlecit (sodium ferric gluconate) — precertification required for Commercial members only August 1, 2026 | Participating provider precertification list for Aetna, Pg 23 Original policy |
| J9331 | Fyarro (sirolimus protein-bound particles for injectable suspension) | Participating provider precertification list for Aetna, Pg 23 Original policy |
| J3490 | Gattex (teduglutidem) | Participating provider precertification list for Aetna, Pg 23 Original policy |
| J9210 | Gamifant (emapalumab-lzsg) — precertification required effective October 1, 2026 | Participating provider precertification list for Aetna, Pg 23 Original policy |
| J0223 | Givlaari (givosiran) — precertification required for the drug and site of care | Participating provider precertification list for Aetna, Pg 23 Original policy |
| J3490 | Genglycos (pariglasgene brecaparvovec)— precertification required for drug effective October 1, 2026 | Participating provider precertification list for Aetna, Pg 23 Original policy |
| J3590 | Genglycos (pariglasgene brecaparvovec)— precertification required for drug effective October 1, 2026 | Participating provider precertification list for Aetna, Pg 23 Original policy |
| C9399 | Genglycos (pariglasgene brecaparvovec)— precertification required for drug effective October 1, 2026 | Participating provider precertification list for Aetna, Pg 23 Original policy |
| Q5169 | Granulocyte-colony stimulating factors: Armlupeg (pegfilgrastim-unne) — precertification required effective April 1, 2026 | Participating provider precertification list for Aetna, Pg 23 Original policy |
| J3490 | Granulocyte-colony stimulating factors: Ennumo (pegfilgrastim-pccg,) — precertification required effective | Participating provider precertification list for Aetna, Pg 23 Original policy |
| J3590 | Granulocyte-colony stimulating factors: Ennumo (pegfilgrastim-pccg,) — precertification required effective | Participating provider precertification list for Aetna, Pg 23 Original policy |
| C9399 | Granulocyte-colony stimulating factors: Ennumo (pegfilgrastim-pccg,) — precertification required effective | Participating provider precertification list for Aetna, Pg 23 Original policy |
| Q5172 | Granulocyte-colony stimulating factors: Filkri (filgrastim-laha) — precertification required effective May 1, 2026 | Participating provider precertification list for Aetna, Pg 23 Original policy |
| Q5108 | Granulocyte-colony stimulating factors: Fulphila (pegfilgrastim-jmdb) — precertification required for commercial only | Participating provider precertification list for Aetna, Pg 23 Original policy |
| Q5130 | Granulocyte-colony stimulating factors: Fylnetra (pegfilgrastim-pbbk) | Participating provider precertification list for Aetna, Pg 23 Original policy |
| J1447 | Granulocyte-colony stimulating factors: Granix (tbo-filgrastim) | Participating provider precertification list for Aetna, Pg 23 Original policy |
| J2820 | Granulocyte-colony stimulating factors: Leukine (sargramostim) | Participating provider precertification list for Aetna, Pg 23 Original policy |
| J2506 | Granulocyte-colony stimulating factors: Neulasta (pegfilgrastim) — precertification required for Commercial members only | Participating provider precertification list for Aetna, Pg 23 Original policy |
| J1442 | Granulocyte-colony stimulating factors: Neupogen (filgrastim) | Participating provider precertification list for Aetna, Pg 23 Original policy |
| Q5110 | Granulocyte-colony stimulating factors: Nivestym (filgrastim-aafi) | Participating provider precertification list for Aetna, Pg 23 Original policy |
| Q5148 | Granulocyte-colony stimulating factors: Nypozi (filgrastim-txid) | Participating provider precertification list for Aetna, Pg 23 Original policy |
| Q5122 | Granulocyte-colony stimulating factors: Nyvepria (pegfilgrastim-apgf) | Participating provider precertification list for Aetna, Pg 23 Original policy |
| Q5125 | Granulocyte-colony stimulating factors: Releuko (filgrastim-ayow) | Participating provider precertification list for Aetna, Pg 23 Original policy |
| J1449 | Granulocyte-colony stimulating factors: Rolvedon (eflapegrastim-xnst) | Participating provider precertification list for Aetna, Pg 23 Original policy |
| J9361 | Granulocyte-colony stimulating factors: Ryzneuta (efbemalenograstim alfa-vuxw) | Participating provider precertification list for Aetna, Pg 23 Original policy |
| Q5127 | Stimufend (pegfilgrastim-fpgk) | Participating provider precertification list for Aetna, Pg 24 Original policy |
| Q5111 | Udenyca (pegfilgrastim-cbvq) | Participating provider precertification list for Aetna, Pg 24 Original policy |
| Q5111 | Udenyca OBI (pegfilgrastim-cbqv) | Participating provider precertification list for Aetna, Pg 24 Original policy |
| Q5120 | Ziextenzo (pegfilgrastim-bmez) | Participating provider precertification list for Aetna, Pg 24 Original policy |
| J3490 | Growth hormone: Skytrofa (lonapegsomatropin-tcgd) — precertification required for Medicare | Participating provider precertification list for Aetna, Pg 24 Original policy |
| J3590 | Growth hormone: Skytrofa (lonapegsomatropin-tcgd) — precertification required for Medicare | Participating provider precertification list for Aetna, Pg 24 Original policy |
| J0597 | Hereditary angioedema agents: Berinert (C1 esterase inhibitor) | Participating provider precertification list for Aetna, Pg 24 Original policy |
| J0598 | Hereditary angioedema agents: Cinryze (C1 esterase inhibitor) — precertification required for the drug and site of | Participating provider precertification list for Aetna, Pg 24 Original policy |
| J3490 | Hereditary angioedema agents: Dawnzera (Donidalorsen Sodium) | Participating provider precertification list for Aetna, Pg 24 Original policy |
| J3590 | Hereditary angioedema agents: Dawnzera (Donidalorsen Sodium) | Participating provider precertification list for Aetna, Pg 24 Original policy |
| C9399 | Hereditary angioedema agents: Dawnzera (Donidalorsen Sodium) | Participating provider precertification list for Aetna, Pg 24 Original policy |
| J1744 | Hereditary angioedema agents: Firazyr SC (icatibant acetate) — precertification required for Commercial | Participating provider precertification list for Aetna, Pg 24 Original policy |
| J0599 | Hereditary angioedema agents: [human]) — precertification required for | Participating provider precertification list for Aetna, Pg 24 Original policy |
| J1290 | Hereditary angioedema agents: Kalbitor (ecallantide) | Participating provider precertification list for Aetna, Pg 24 Original policy |
| J0596 | Hereditary angioedema agents: Ruconest (C1 esterase inhibitor) | Participating provider precertification list for Aetna, Pg 24 Original policy |
| J1744 | Hereditary angioedema agents: Sajazir SC (icatibant acetate) — precertification required for Commercial | Participating provider precertification list for Aetna, Pg 24 Original policy |
| J0593 | Hereditary angioedema agents: Takhzyro (lanadelumab-flyo) | Participating provider precertification list for Aetna, Pg 24 Original policy |
| J0225 | (ATTR) drugs: Amvuttra (vutrisiran) — precertification required for the drug and site of care | Participating provider precertification list for Aetna, Pg 24 Original policy |
| J0222 | (ATTR) drugs continued: Onpattro (patisiran) — precertification required for the drug and site of care | Participating provider precertification list for Aetna, Pg 24 Original policy |
| C9311 | (ATTR) drugs continued: Wainua (eplontersen) | Participating provider precertification list for Aetna, Pg 24 Original policy |
| J9358 | HER2 receptor drugs: deruxtecan-nxki) | Participating provider precertification list for Aetna, Pg 24 Original policy |
| J9355 | HER2 receptor drugs: Herceptin (trastuzumab) — precertification required for the drug and site of care | Participating provider precertification list for Aetna, Pg 24 Original policy |
| J9356 | HER2 receptor drugs: hyaluronidase-oysk) | Participating provider precertification list for Aetna, Pg 24 Original policy |
Aetna precertification list
The participating-provider examples point at the official list. Open the list itself for the current file, including its effective date.
Plan and setting exceptions
Student Health and Allina Health / Aetna are separate from the participating-provider rows above.
Prior authorization forms
| Product or plan | Benefit | Route |
|---|---|---|
| Use the plan named on the official form page | Medical and pharmacy forms are listed by Aetna | Aetna health care professional forms |
This page does not reproduce a form and does not list a fax number that was not read from the form page.