Aetna prior authorization and CPT code lookup, page 20
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 |
|---|---|---|
| J2351 | Multiple sclerosis drugs (precertification required for the drug and site of care): ocsq) | Participating provider precertification list for Aetna, Pg 28 Original policy |
| Q5134 | Multiple sclerosis drugs (precertification required for the drug and site of care): Tyruko (natalizumab-sztn) | Participating provider precertification list for Aetna, Pg 28 Original policy |
| J2323 | Multiple sclerosis drugs (precertification required for the drug and site of care): Tysabri (natalizumab) | Participating provider precertification list for Aetna, Pg 28 Original policy |
| J1426 | Muscular dystrophy drugs: (precertification required for the drug and site of care): Amondys 45 (casimersen) | Participating provider precertification list for Aetna, Pg 28 Original policy |
| J3490 | Muscular dystrophy drugs: (precertification required for the drug and site of care): Elevidys (delandistrogene moxeparvovec) | Participating provider precertification list for Aetna, Pg 28 Original policy |
| J3590 | Muscular dystrophy drugs: (precertification required for the drug and site of care): Elevidys (delandistrogene moxeparvovec) | Participating provider precertification list for Aetna, Pg 28 Original policy |
| C9399 | Muscular dystrophy drugs: (precertification required for the drug and site of care): Elevidys (delandistrogene moxeparvovec) | Participating provider precertification list for Aetna, Pg 28 Original policy |
| J1428 | Muscular dystrophy drugs: (precertification required for the drug and site of care): Exondys 51 (eteplirsen) | Participating provider precertification list for Aetna, Pg 28 Original policy |
| J1427 | Muscular dystrophy drugs: (precertification required for the drug and site of care): Viltepso (viltolarsen) | Participating provider precertification list for Aetna, Pg 28 Original policy |
| J1429 | Muscular dystrophy drugs: (precertification required for the drug and site of care): Vyondys 53 (golodirsen) | Participating provider precertification list for Aetna, Pg 28 Original policy |
| Q5107 | Mvasi (bevacizumab-awwb) — precertification required for the drug and site of care for oncology indications only | Participating provider precertification list for Aetna, Pg 28 Original policy |
| J3490 | Myalept (metreleptin) — precertification required for Commercial members only | Participating provider precertification list for Aetna, Pg 28 Original policy |
| J3590 | Myalept (metreleptin) — precertification required for Commercial members only | Participating provider precertification list for Aetna, Pg 28 Original policy |
| J9038 | Niktimvo (axatilimab-csfr) | Participating provider precertification list for Aetna, Pg 28 Original policy |
| J1809 | Nulibry (fosdenopterin) | Participating provider precertification list for Aetna, Pg 29 Original policy |
| J3406 | Omisirge (omidubicel - onlv) — precertification required for the drug only effective October 1, 2026 | Participating provider precertification list for Aetna, Pg 29 Original policy |
| Q5150 | Ophthalmic injectables: Ahzantive (aflibercept-mrbb) | Participating provider precertification list for Aetna, Pg 29 Original policy |
| J0179 | Ophthalmic injectables: Beovu (brolucizumab-dbll) | Participating provider precertification list for Aetna, Pg 29 Original policy |
| Q5124 | Ophthalmic injectables: Byooviz (ranibizumab-nuna) | Participating provider precertification list for Aetna, Pg 29 Original policy |
| Q5128 | Ophthalmic injectables: Cimerli (ranibizumab-eqrn) | Participating provider precertification list for Aetna, Pg 29 Original policy |
| J3403 | Ophthalmic injectables: Encelto (revakinagene taroretcel-lwey) | Participating provider precertification list for Aetna, Pg 29 Original policy |
| Q5149 | Ophthalmic injectables: Enzeevu (aflibercept-abzv) | Participating provider precertification list for Aetna, Pg 29 Original policy |
| Q5170 | Ophthalmic injectables: Eydenzelt (aflibercept-boav) — precertification required effective April 1, 2026 | Participating provider precertification list for Aetna, Pg 29 Original policy |
| J0178 | Ophthalmic injectables: Eylea (aflibercept) | Participating provider precertification list for Aetna, Pg 29 Original policy |
| J0177 | Ophthalmic injectables: Eylea HD (aflibercept) | Participating provider precertification list for Aetna, Pg 29 Original policy |
| J2782 | Ophthalmic injectables: Izervay (avacincaptad pegol) | Participating provider precertification list for Aetna, Pg 29 Original policy |
| J2778 | Ophthalmic injectables: Lucentis (ranibizumab) | Participating provider precertification list for Aetna, Pg 29 Original policy |
| J3490 | Ophthalmic injectables: Lumvoa (veligrotug-vvze,) —precertification required for the drug and site | Participating provider precertification list for Aetna, Pg 29 Original policy |
| J3590 | Ophthalmic injectables: Lumvoa (veligrotug-vvze,) —precertification required for the drug and site | Participating provider precertification list for Aetna, Pg 29 Original policy |
| C9399 | Ophthalmic injectables: Lumvoa (veligrotug-vvze,) —precertification required for the drug and site | Participating provider precertification list for Aetna, Pg 29 Original policy |
| J3398 | Ophthalmic injectables: Luxturna (voretigene neparvovec-rzyl) — precertification required for the drug and site of | Participating provider precertification list for Aetna, Pg 29 Original policy |
| J3490 | Ophthalmic injectables: Lytenava (bevacizumab-vikg,) — precertification required effective | Participating provider precertification list for Aetna, Pg 29 Original policy |
| J3590 | Ophthalmic injectables: Lytenava (bevacizumab-vikg,) — precertification required effective | Participating provider precertification list for Aetna, Pg 29 Original policy |
| J9999 | Ophthalmic injectables: Lytenava (bevacizumab-vikg,) — precertification required effective | Participating provider precertification list for Aetna, Pg 29 Original policy |
| Q5168 | Ophthalmic injectables: Nufymco (ranibizumab-leyk) — precertification required effective May 1, 2026 | Participating provider precertification list for Aetna, Pg 29 Original policy |
| Q5153 | Ophthalmic injectables: Opuviz (aflibercept-yszy) | Participating provider precertification list for Aetna, Pg 29 Original policy |
| Q5147 | Ophthalmic injectables: Pavblu (aflibercept-ayyh) | Participating provider precertification list for Aetna, Pg 29 Original policy |
| J3490 | Ophthalmic injectables: Ranluspec (ranibizumab-hkdz,, | Participating provider precertification list for Aetna, Pg 29 Original policy |
| J3590 | Ophthalmic injectables: Ranluspec (ranibizumab-hkdz,, | Participating provider precertification list for Aetna, Pg 29 Original policy |
| C9399 | Ophthalmic injectables:)— precertification required effective | Participating provider precertification list for Aetna, Pg 29 Original policy |
| J2779 | Ophthalmic injectables: Susvimo (ranibizumab) | Participating provider precertification list for Aetna, Pg 29 Original policy |
| J2781 | Ophthalmic injectables: Syfovre (pegcetacoplan) | Participating provider precertification list for Aetna, Pg 29 Original policy |
| J3241 | Ophthalmic injectables (continued): Tepezza (teprotumumab-trbw) — precertification required for the drug and site of | Participating provider precertification list for Aetna, Pg 29 Original policy |
| J2777 | Ophthalmic injectables (continued): Vabysmo (faricimab-svoa) | Participating provider precertification list for Aetna, Pg 29 Original policy |
| Q5155 | Ophthalmic injectables (continued): Yesafili (aflibercept-jbvf) | Participating provider precertification list for Aetna, Pg 29 Original policy |
| Q5161 | Osteoporosis drugs: Aukelso (denosumab-kyqq) — precertification required effective April 1, 2026 — precertification required for site of | Participating provider precertification list for Aetna, Pg 29 Original policy |
| Q5162 | Osteoporosis drugs: Bildyos (denosumab-nxxp) — precertification required effective April 1, 2026 | Participating provider precertification list for Aetna, Pg 29 Original policy |
| Q5162 | Osteoporosis drugs: Bilprevda (denosumab-nxxp) — precertification required effective April 1, 2026 — precertification required for site of | Participating provider precertification list for Aetna, Pg 29 Original policy |
| Q5158 | Osteoporosis drugs: Bomyntra (denosumab-bnht) — precertification required for drug and site of | Participating provider precertification list for Aetna, Pg 29 Original policy |
| Q5171 | Osteoporosis drugs: Boncresa (denosumab-mobz) — precertification required effective July 1, 2026 | Participating provider precertification list for Aetna, Pg 29 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.