Health Care Professionals: Pharmacy Management Program FAQs

How do I become a participating provider to service Aetna members?

Effective January 1, 2011 CVS/Caremark became the pharmacy benefits administrator for Aetna Pharmacy Network.

In order to service Aetna members you will need to be a participating provider with Caremark. You can contact Caremark via e-mail at networkcommunications@caremark.com or via telephone at 866-488-4708.

Include the following information in your fax or e-mail requests:

Enrollment packets will be mailed within 1-3 days. The entire enrollment process, including credentialing, takes about 10 business days — provided we receive all the information needed to process your request.

Whom do I call when I have questions regarding Aetna's prescription drug programs?
Call one of our Aetna Pharmacy Management customer service professionals. You can reach them toll free at 1-800-238-6279.

Our customer service professionals are available 24 hours a day, every day. They can help you with questions regarding claims processing, member eligibility, Maximum Allowable Cost (MAC List), Aetna's preferred drug list (also called a formulary), and other related issues. 

How can I support the Aetna Preferred Drug List and the precertification and step-therapy programs?
As a pharmacist participating in our network, you play an important role in caring for Aetna members. Let’s say a member presents a prescription for a drug that:

  • Needs precertification or prerequisite therapy, or
  • Is on the Formulary Exclusions List and may not be covered

Please help our members. Intervene on their behalf by contacting the prescribing doctor. 
The doctor may want to request a medical exception so that a Formulary Exclusions List drug or step-therapy drug will be covered. If so, tell the doctor to contact the Aetna Pharmacy Management Precertification Unit. He or she can fax the request to 1-800-408-2386 or call 1-800-414-2386.

See our Pharmacy Clinical Policy Bulletins. There you will find Aetna Pharmacy Management's guidelines for determining health care coverage for selected outpatient prescription drugs.

In cases where a physician has prescribed an analgesic or antibiotic that requires medical exception or precertification, you may initiate the process by calling the Precertification Unit directly. If the Precertification Unit is closed, you may dispense one filling for an analgesic or antibiotic to an eligible Aetna member in accordance with the contracted rates. When the Precertification Unit reopens, you must call to receive authorization to transmit the claim online. 

What is the Member ID number format?
You will see Member ID cards with numeric and alpha-numeric member numbers. In addition, there are Preferred Provider Organization (PPO) and Managed Choice (MC) plans that are social security number-based.

It is a good idea to request to see the Member ID card prior to filling any new prescription.
If you have any problems transmitting a claim, call one our Customer Services professionals at 1-888-792-8742. They are available 24 hours a day, every day to help you.

Do I need to enter a person code or group number when transmitting a claim?
Neither a person code nor group number is required to process Aetna claims. [link to 3.2.5]However, if your particular computer system requires you to enter something in the group number field, enter the default group number of 00670000.

What BIN code do I use to process claims?
All prescriptions submitted to Aetna for online adjudication must use BIN code 610502. Your software vendor will help you to obtain and install/set up the necessary software to submit claims online. If you have any problems or questions, call one of our customer service professionals at 1-888-792-8742. They are available 24 hours a day, every day to help you.

Does Aetna provide a public website for members and consumers?
Yes. The Aetna Pharmacy area helps members maximize their pharmacy benefits program by providing tools and resources to manage their health and reduce medication costs.

How can I find out what changes will take place in 2014 to Commercial preferred drugs and those impacted by precertification, step therapy or quantity limits?
Please refer to the 2014 Summary of Changes for Commercial (Non-Medicare) plans.
 (PDF, 157 KB).

Where can I locate the 2014 Aetna Provider Preferred Drug Guide?
You can access it online. Please visit www.aetna.com/formulary for the most current information. Or, you can order a paper copy of this guide by returning the reply card .  (PDF, 100 KB)
You will receive a printed copy in fall 2012.  If you have questions, please call the Aetna Pharmacy Management Provider Help Line toll-free at 1-800-AETNA RX (1-800-238-6279).

Feedback
You are now leaving the Aetna website.

Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites.

Continue >