Pharmacy: Coverage and costs FAQs

Coverage

Is my medicine covered?
To see if a drug is covered by your plan, log in to your Aetna Navigator website and click on the Pharmacy Benefits Summary link. Then, search by drug name using Medication Search. You can also email Member Services to ask questions about your drug coverage. Just click the Contact Us link in Aetna Navigator.

Are diabetic supplies covered under my prescription plan?
All plans cover insulin. Coverage for other diabetic supplies varies by plan. See if your plan covers diabetic supplies by visiting Aetna Navigator. You'll find an answer under Benefits/Summary. You can also email Member Services to ask questions about your drug coverage. Click the Contact Us link to send your question.

Why isn't my medication covered?
There are several reasons why a medication may not be covered:

• It is experimental or new.
• Your doctor prescribed the medication for a use not recognized by the U.S. Food and Drug Administration or other professional medical organizations.
• It was dispensed in your doctor's office (example: a measles vaccine). Drugs dispensed in a doctor's office are not covered under your pharmacy benefits; your medical benefits may provide coverage.
• What you thought was a medication is actually a medical device. Glucose monitors for those with diabetes is an example. These devices show if a drug treatment is having its intended effect; it may be covered by your medical plan instead of your pharmacy plan.
• There are equivalent over-the-counter medications available.
• Your employer does not offer all benefits available through your pharmacy benefits provider. For example, pharmacy benefit plans may cover injectable fertility medications for one pharmacy plan member but not for another based on the plan chosen by the employer. 
• Research indicates that the drug is not for safe for some people.
• Your pharmacy benefits coverage with Aetna has terminated.

Learn more about why your pharmacy benefits plan may not cover a drug by calling the number on your member ID card. You can buy any drug your doctor prescribes, even if it is not covered by your plan; you will have to pay the full cost of the medication.  If you are an Aetna pharmacy member and are denied coverage for a medication, talk to your doctor. He or she can advise you on the best steps to take.

How do I find out if I can take another drug in place of one that's not covered?
Talk to your doctor about alternatives. To see if an alternative drug is covered: 

• Call Member Services at the toll-free number on your member ID card. 
• Log in to Aetna Navigator, click on Pharmacy Benefits Summary and then use the Medication Search  tool.

Costs 

How much is my copay?
See your copay information in Aetna Navigator. Just click on the Benefits/Summary link. You can also call Aetna Member Services at the number on your member ID card to ask a benefits question.

Why do my prescriptions cost so much?
If you're like most people with prescription drug coverage, you share the cost of your medications with your insurance provider and your employer. Your share of the cost is called a copay or coinsurance.

Some plans offer lower copays for less costly drugs. For example, they charge one copay for a generic drug, a higher copay for a preferred brand-name drug, and a still higher copay for a non-preferred drug.

Coinsurance is a percent of the drug's cost. When you pay a percentage, your cost may be high for many reasons:

• The cost of the drug may be high. Let's assume your coinsurance is 30%. In this case, a $250 drug will be more costly than a $25 drug.
• You may have to meet a deductible before coverage begins.
• Your drug may not be on the Preferred Drug List, so you pay at a higher tier.
• You may be buying a more expensive brand-name drug when there is a generic equivalent available for less money.

Learn about your coverage tiers by logging in to Aetna Navigator. Then, click on the Benefits/Summary link. Or, call us at the number on your member ID card to ask questions about your benefits.

If your doctor prescribed a drug that has a higher copay or coinsurance, ask if there is a lower-cost alternative that may work for you.

Can I get reimbursed for prescription medications I bought from a pharmacy that is not in Aetna's network?
Yes. When you use a pharmacy that is not in the Aetna network, you pay the full amount at the time of purchase and submit a claim for reimbursement -- less your applicable copay or coinsurance amounts (subject to limitations and restrictions.)

Refer to your Certificate of Coverage or Benefits Booklet for details; or, call a Member Services representative at the toll-free number on your member ID card.  To submit a claim for reimbursement, please follow the steps below. The following documents are provided in Adobe PDF format. 

• Keep your receipt(s) for all prescription(s) that you paid out of your pocket. Receipt(s) must have a legible member ID number on it.
• Print and complete the Prescription Drug Claim form (2 pages) or, if you have a Medicare plan, the Medicare Prescription Drug Claim form (2 pages).
• Mail receipt(s) and claim form to:
  
  Aetna Pharmacy Management
  Attn. Claim Processing
  PO Box 398106
  Minneapolis, MN 55439
  
• To be eligible for reimbursement, submit your paperwork within two years of the date of purchase.