Aetna prior authorization and CPT code lookup, page 22
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 |
|---|---|---|
| J3490 | penpulimab-kcqx | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J3590 | penpulimab-kcqx | Participating provider precertification list for Aetna, Pg 31 Original policy |
| C9399 | penpulimab-kcqx | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J9022 | Tecentriq (atezolizumab) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J9024 | hyaluronidase-tqjs) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J9329 | Tevimbra (tislelizumab) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J9275 | Unloxcyt (cosibelimab-ipdl) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J9345 | Zynyz (retifanlimab-dlwr) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J0208 | Pedmark (sodium thiosulfate) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J9304 | Pemfexy (pemetrexed) — precertification required for Medicare Advantage members. precertification required for commercial members effective July 1, 2026 | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J9324 | Pemrydi RTU (pemetrexed) — precertification required for Medicare Advantage members precertification required for commercial members effective July 1, 2026 | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J9309 | Polivy (polatuzumab vedotin-piiq) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| Q2043 | Provenge (sipuleucel-T) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J1325 | Pulmonary arterial hypertension drugs: Flolan (epoprostenol sodium) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J3285 | Pulmonary arterial hypertension drugs: Remodulin (treprostinil sodium) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J7686 | Pulmonary arterial hypertension drugs: Remodulin (treprostinil sodium) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J3285 | (continued): Tyvaso (treprostinil) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J7686 | (continued): Tyvaso (treprostinil) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J1325 | (continued): Veletri (epoprostenol sodium) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| Q4074 | (continued): Ventavis (iloprost) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J3490 | (continued): Winrevair (sotatercept-csrk,) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J3590 | (continued): Winrevair (sotatercept-csrk,) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| C9399 | (continued): Winrevair (sotatercept-csrk,) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| A9513 | Radiopharmaceutical drugs: Lutathera (lutetium Lu 177 dotatate) — precertification required effective October 1, | Participating provider precertification list for Aetna, Pg 31 Original policy |
| A9600 | Radiopharmaceutical drugs: Metastron (Strontium-89 Chloride injection) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| A9607 | Radiopharmaceutical drugs: Pluvicto (lutetium Lu 177 vipivotide tetraxetan) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| A9606 | Radiopharmaceutical drugs: Xofigo (radium Ra 223 dichloride) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J0896 | Reblozyl (luspatercept-aamt) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J3490 | (plozasiran) — precertification | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J2786 | Respiratory injectables (precertification required for the drug and site of care): Cinqair (reslizumab) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J2361 | Respiratory injectables (precertification required for the drug and site of care): Exdensur (depemokimab) — precertification required effective April 1, 2026 | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J0517 | Respiratory injectables (precertification required for the drug and site of care): Fasenra (benralizumab) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J2182 | Respiratory injectables (precertification required for the drug and site of care): Nucala (mepolizumab) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| Q5154 | Respiratory injectables (precertification required for the drug and site of care): Omlyclo (omalizumab-igec) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J2356 | Respiratory injectables (precertification required for the drug and site of care): Tezspire (tezepelumab-ekko) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J2357 | Respiratory injectables (precertification required for the drug and site of care): Xolair (omalizumab) | Participating provider precertification list for Aetna, Pg 31 Original policy |
| J3490 | Revtorpyk (gedatolisib,)— precertification required effective September 1, 2026 | Participating provider precertification list for Aetna, Pg 32 Original policy |
| J3590 | Revtorpyk (gedatolisib,)— precertification required effective September 1, 2026 | Participating provider precertification list for Aetna, Pg 32 Original policy |
| J9999 | Revtorpyk (gedatolisib,)— precertification required effective September 1, 2026 | Participating provider precertification list for Aetna, Pg 32 Original policy |
| C9399 | Revtorpyk (gedatolisib,)— precertification required effective September 1, 2026 | Participating provider precertification list for Aetna, Pg 32 Original policy |
| J3490 | Rivfloza (nedosiran,) — precertification required for the drug and site of care | Participating provider precertification list for Aetna, Pg 32 Original policy |
| J3590 | Rivfloza (nedosiran,) — precertification required for the drug and site of care | Participating provider precertification list for Aetna, Pg 32 Original policy |
| C9399 | Rivfloza (nedosiran,) — precertification required for the drug and site of care | Participating provider precertification list for Aetna, Pg 32 Original policy |
| J9061 | Rybrevant (amivantamab-vmjw) | Participating provider precertification list for Aetna, Pg 32 Original policy |
| J9062 | Rybrevant Faspro (amivantamab and hyaluronidase-lpuj) — precertification required for the drug and site of care effective April 1, 2026 | Participating provider precertification list for Aetna, Pg 32 Original policy |
| J3402 | Ryoncil (remestemcel-L) | Participating provider precertification list for Aetna, Pg 32 Original policy |
| J2998 | Ryplazim (plasminogen, human-tvmh) | Participating provider precertification list for Aetna, Pg 32 Original policy |
| J0870 | Rytelo (imetelstat) | Participating provider precertification list for Aetna, Pg 32 Original policy |
| J0491 | Saphnelo (anifrolumab-fnia) — precertification required for the drug and site of care | Participating provider precertification list for Aetna, Pg 32 Original policy |
| J3490 | Saphnelo SC (Anifrolumab-fnia) — precertification required for the drug and site of care effective July 1, 2026. | Participating provider precertification list for Aetna, Pg 32 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.