Aetna prior authorization and CPT code lookup, page 17
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 |
|---|---|---|
| Q5146 | HER2 receptor drugs: Hercessi (trastuzumab-strf) — precertification required for the drug and site of | Participating provider precertification list for Aetna, Pg 24 Original policy |
| Q5113 | HER2 receptor drugs: Herzuma (trastuzumab-pkrb) — precertification required for the drug and site of | Participating provider precertification list for Aetna, Pg 24 Original policy |
| J9354 | HER2 receptor drugs: Kadcyla (ado-trastuzumab emtansine) — precertification required for the drug and site of | Participating provider precertification list for Aetna, Pg 24 Original policy |
| Q5117 | HER2 receptor drugs: Kanjinti (trastuzumab-anns) — precertification required for the drug and site of | Participating provider precertification list for Aetna, Pg 24 Original policy |
| J9353 | HER2 receptor drugs: Margenza (margetuximab-cmkb) | Participating provider precertification list for Aetna, Pg 24 Original policy |
| Q5114 | HER2 receptor drugs: Ogivri (trastuzumab-dkst) — precertification required for the drug and site of | Participating provider precertification list for Aetna, Pg 24 Original policy |
| Q5112 | HER2 receptor drugs: Ontruzant (trastuzumab-dttb) — precertification required for the drug and site of | Participating provider precertification list for Aetna, Pg 24 Original policy |
| J9306 | HER2 receptor drugs: Perjeta (pertuzumab) — precertification required for the drug and site of care | Participating provider precertification list for Aetna, Pg 24 Original policy |
| J9316 | HER2 receptor drugs: hyaluronidase-zzxf) | Participating provider precertification list for Aetna, Pg 24 Original policy |
| J3490 | Poherdy (pertuzumab-dpzb,, | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J3590 | Poherdy (pertuzumab-dpzb,, | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J9999 | )— precertification required for drug and | Participating provider precertification list for Aetna, Pg 25 Original policy |
| Q5116 | Trazimera (trastuzumab-qyyp) — precertification required for the drug and site of | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J9276 | Ziihera (zanidatamab-hrii) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J0901 | PH) inhibitors: Vafseo (vadadustat) — precertification required for Medicare Advantage members only | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J0638 | Ilaris (canakinumab)— precertification required for drug and site of care effective April 1, 2026. | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J9026 | Imdelltra (tarlatamab-dlle) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J9325 | Imlygic (talimogene laherparepvec) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J9347 | Imjudo (tremelimumab) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J1552 | Immunoglobulins (precertification required for the drug and site of care): stwk) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J1554 | Immunoglobulins (precertification required for the drug and site of care): Asceniv (immune globulin) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J1556 | Immunoglobulins (precertification required for the drug and site of care): Bivigam (immune globulin) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J1551 | Immunoglobulins (precertification required for the drug and site of care): Cutaquig (immune globulin) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J1555 | Immunoglobulins (precertification required for the drug and site of care): Cuvitru (immune globulin SC [human]) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J1572 | Immunoglobulins (precertification required for the drug and site of care):)— precertification required effective | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J1460 | Immunoglobulins (precertification required for the drug and site of care): GamaSTAN (immune globulin) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J1560 | Immunoglobulins (precertification required for the drug and site of care): GamaSTAN (immune globulin) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J1569 | Immunoglobulins (continued): Gammagard (immune globulin) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J1569 | Immunoglobulins (continued): Gammagard ERC (immune globlin) — precertification required effective March 1, 2026 | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J1566 | Immunoglobulins (continued): Gammagard S/D (immune globulin) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J1561 | Immunoglobulins (continued): Gammaked (immune globulin) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J1557 | Immunoglobulins (continued): Gammaplex (immune globulin) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J1561 | Immunoglobulins (continued): Gamunex-C (immune globulin) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J1559 | Immunoglobulins (continued): Hizentra (immune globulin) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J1575 | Immunoglobulins (continued): HyQvia (immune globulin) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J1568 | Immunoglobulins (continued): Octagam (immune globulin) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J1576 | Immunoglobulins (continued): Panzyga (immune globulin) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J1459 | Immunoglobulins (continued): Privigen (immune globulin) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J1577 | Immunoglobulins (continued): kthm) — precertification required for the | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J1558 | Immunoglobulins (continued): Xembify (immune globulin) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J1553 | Immunoglobulins (continued): human – dira, | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J3262 | Immunologic agents: Actemra IV (tocilizumab) — precertification required for the drug and site of care | Participating provider precertification list for Aetna, Pg 25 Original policy |
| Q5156 | Immunologic agents: Avtozma (tocilizumab-anoh) — precertification required for the drug and site of | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J0717 | Immunologic agents: Cimzia (certolizumab pegol) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J3247 | Immunologic agents: Cosentyx IV (secukinumab) | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J3490 | Immunologic agents: Enspryng (satralizumab) — precertification required for Medicare | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J3590 | Immunologic agents: Enspryng (satralizumab) — precertification required for Medicare | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J3380 | Immunologic agents: Entyvio (vedolizumab) — precertification required for the drug and site of care | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J9301 | Immunologic agents: Gazyva (obinutuzumab) — precertification required for Commercial members effective | Participating provider precertification list for Aetna, Pg 25 Original policy |
| J3245 | Immunologic agents: Ilumya (tildrakizumab) | Participating provider precertification list for Aetna, Pg 25 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.