Aetna Public Employees Plan - Request for Obesity Surgery

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Request for Obesity Surgery - Online (below)
or By Mail (click here)

You must answer all questions for your information to be submitted for medical review.

Subscriber I.D. number (from the front of your Aetna I.D. card) Include the prefix "W" with the first four digits.


W (4 digits)	(5 digits)

Your date of birth (enter as mm/dd/yyyy)

/ /

What is your age in years?

How tall are you (in feet and inches) without shoes on?

ft. in.

How much do you weigh without shoes on?

Pounds

What is your gender?

Male Female

Have you been diagnosed with diabetes?

Yes No

What was your most recent hemoglobin A1C?

Have you been diagnosed with high blood pressure?

Yes No

Have you been diagnosed with sleep apnea?

Yes No

Have you been diagnosed with heart disease?

Yes No

Have you been diagnosed with high cholesterol or high lipids?

Yes No

What medications are you taking?

What is your daytime phone number?

( ) -

Your answers will be reviewed by the Aetna Public Employees Plan Medical Review staff to determine if your medical condition fits the criteria for coverage of obesity surgery. You will receive a letter within 14 days letting you know if you have been accepted into the presurgical program for obesity surgery.

If the Aetna Public Employees Plan finds that you do meet the criteria for entrance into the presurgical program, your letter will have the phone number of a case manager for you to call and set up a phone appointment. During that appointment, the case manager will explain the program requirements. After you have met all requirements, an Aetna Public Employees Plan medical director will review your file. The medical director will make the final determination whether the Aetna Public Employees Plan will cover obesity surgery for you.

Please do not send any other paperwork or records at this time.

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