Pharmacy: Plan requirements and network FAQs

Plan requirements

What is precertification?
Precertification is one way that we can help you and your doctor find safe, appropriate drugs and keep costs down.

Precertification means that you or your doctor need to get approval from the plan before certain drugs will be covered.

Generally, precertification applies to drugs that:

  • Are often taken in the wrong way.
  • Should only be used for certain conditions.
  • Often cost more than other drugs that are proven to be just as effective.

What is an example of precertification?

  • An 8-year-old member needs an antibiotic called tetracycline.
  • This drug should be carefully prescribed for children ages 8 and under. There is a risk it can change the color of their teeth.
  • As a result, precertification is required. It makes sure the child has a medical need for the drug. If so, the drug will be approved for coverage.

What is step therapy?
For some drugs (known as step-therapy drugs), you may need to try certain other drugs first before the plan will cover that step-therapy drug. These other drugs are called prerequisite drugs. They are used to treat the same conditions and may actually cost less.

What are quantity limits?
Some drugs have a limit on how many doses you can get. You may need approval first if your doctor prescribes more than what is recommended. This applies to drugs that:

  • Are often taken in the wrong way
  • Are often taken in amounts greater than the recommended dose

What is an example of quantity limits?

  • A member needs Imitrex.
  • Two prescriptions are written: The first is for nine tablets of Imitrex 50mg. The other is for nine tablets of Imitrex 100mg. This totals 18 tablets per month using both strengths. But the quantity limit for the drug is nine tablets per month.
  • The member has a medical need for the two strengths and amounts requested.
  • The prescribing doctor must contact Aetna to ask for an exception.

When we precertify a drug, we check that the member's age or gender is within the recommended dosing guidelines. We may look for duplications in drug therapies or check that a medication is being used based on generally accepted medical criteria.

Generally, the following types of drugs are subject to precertification:

  • Drugs that are likely to be taken incorrectly
  • Drugs that may be prescribed for inappropriate reasons
  • Drugs that may be used in amounts that exceed the recommended dose or length of treatment 
  • Drugs that are more expensive than other drugs that are clinically or therapeutically similar (in other words, alternatives that are just as likely to help you but cost less)

The drug my doctor prescribed requires precertification, step-therapy or has quantity limits. How can I get an exception if necessary?
You may have a medical need for a specific drug. If that drug requires precertification, step therapy  or quantity limits, you may be able to bypass these reviews. Your doctor can ask for a medical exception. To do so, your doctor can contact Aetna and provide the required clinical documentation. If approved, your doctor will be notified. In some cases, you will also be notified. If not approved, you can still get the drug. But you will need to pay the full price of the prescription.

To request an exception, your doctor can reach us in one of the following ways:

  • Call the Aetna Pharmacy Precertification Unit at 1-800-414-2386.
  • Fax a Medical Exception/Precertification Request.
  • Write to:
    Attn: Pharmacy Precertification Unit
    300 Highway 169 South
    Suite 500
    Minneapolis, MN  55426
  • Submit forms through our secure Provider website via NaviNet

While working with your doctor is the preferred way to request an exception, you - or the person you appoint to help you - may wish to make the request. To do so, call us at the phone number above. Or write to our Precertification Unit at the address listed.

As a member, you can also make a precertification or medical exception request to the Aetna Pharmacy Precertification Unit online by clicking "Contact Us" on Aetna Navigator, your secure member website.

 
Pharmacy network

How do I know which pharmacies in my area participate in the Aetna network?
Visit our DocFind® online directory and choose "Pharmacy" from the Provider category. This will help you search our network for participating pharmacies near you.

I'll be out of town for a while. How can I get an extra supply of my prescription medication?
When you know you'll be away and may run out of your prescription during your trip, you can request an extra supply before you go. Go to the Aetna participating pharmacy where you filled the original prescription.  Your pharmacist may call Aetna for an exception that lets you get an early refill of your medication.

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