Aetna Pharmacy Service Request Form

Instructions: Please fill out the form with all information necessary for Client Services to investigate this Service Request. Once the form is submitted you will receive an email confirmation with a case number and the name of the team member assigned to your Service Request. * Denotes a Required Field

If you are having issues or technical difficulties submitting the webform or have feedback or comments, Click Here

This form is only for clients that have Aetna Pharmacy benefits. If your client has Aetna medical and pharmacy is carved out to another PBM, please contact that PBM directly for pharmacy issues.

Your Contact Information

Name

Email Address

Additional Email Address

Use this field if you need to enter a second email address for the team to use when responding to this issue. DO NOT enter a member's email address in either email field.

Is this an escalated request?

What department are you from?

Please Choose Your Type of Request

Member access to care option: Member prescription issue, such as PA, delivery issue, claims adjudication, etc.; specific to a single member

Plan coding question/issue option: Suspected or potential claims processing error, or confirm how a claim is paying

Group Level Issue?

YesNo

Member Information

Member Name

DO NOT ENTER SSNs IN THIS FIELD OR ANYWHERE IN THIS FORM!!

Member ID

Member's Date of Birth

Plan Sponsor Information

Plan Sponsor Name

Product

The Service Request webform is no longer being used for Medicare inquiries. Please send your request directly to RS9040@CVSHealth.com for assistance. Thank you

Control/Group Number

For Medicare Submissions Click Here .

PSU/Account Number

Use 0000000 as the PSU only if there is no active PSU/Account number, otherwise enter the correct PSU for the plan sponsor. If you do not know the plan sponsor's PSU, please CLICK HERE to view instructions on how to look it up.

Is the client at Risk?

Who is the consultant/broker for the client?

Due Date

Request Information

Type of Support Requested

Talking points will be provided on all email support requests.

Meeting Date

Please provide a business need for virtual meeting support

Is the client at risk? does the consultant have pharmacy representative at the meeting? does the client have an issue the requires pharmacy support?

Please choose the type of Service Request you are submitting

Please choose the type of Consultative Support you are requesting

Report Details

Funding Type

Who is the Medical UW?

FI client utilization reviews require Medical UW approval prior to releasing.

How will the data be shared?

Why is the report needed?

Reporting Timeframe Start Date

Reporting Timeframe End Date

Please describe your request

Please summarize your request - DO NOT cut and paste an email in this field.

PLEASE PROVIDE DETAILS ON YOUR REQUEST (Character limit 255)

Attachment

If you need immediate member assistance for an Aetna commercial member, please contact Commercial Client Support.

Contact information 1-866-893-0927 or email ClientSupportAetna@Caremark.com

Hours of operation: Monday – Friday 7am – 7 pm CST

Types of concerns they can assist with:

- General benefit inquiries

- Questions about how a claim is paid

- Overrides within Aetna guidelines

-Mail order issues and questions

- Prior authorization status

Contact Information