Pharmacy: Plan requirements and network FAQs

Plan requirements

What is precertification?
Some plans may require your doctor to request approval from Aetna for coverage of certain medications. This encourages appropriate and cost-effective use of medications by allowing coverage only when certain conditions are met.

Log in to Aetna Navigator. Then, select Pharmacy Benefits Summary and use the Medication Search to see if your medications require precertification.

• Your doctor must contact Aetna to request coverage approval for medications listed on the precertification list.
• If the request is approved, we'll notify your doctor. The medication will be covered at the applicable copay or coinsurance under your plan. We'll notify you, too, if your state requires member notification.
• If the request is denied, we'll notify you and your doctor. You can still purchase the medication at the full price, or talk to your doctor about covered alternatives.

Why does my doctor have to precertify some drugs?
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 precertification program is based on current medical findings, FDA-approved manufacturer labeling information and cost and manufacturer rebate arrangements.

Why do some medications have quantity limits?
Quantity limits are part of the precertification program. They promote appropriate and efficient drug use and enhance patient safety. Limits are based on generally accepted guidelines, efficient dosing regimens and dosing recommendations. There are three types of quantity limits:

1. Dose Efficiency Edits - Limits coverage of prescriptions to one dose per day for drugs that are approved for once-daily use.
2. Maximum Daily Dose - Informational message is sent to the pharmacy if prescription lies outside recommended minimum and maximum doses.
3. Quantity Limits Over Time - Limits coverage of prescriptions to a specific number of units per a defined amount of time.

Quantity limit medications may be covered for quantities up to those indicated. In order to receive coverage for amounts over the quantity listed, the prescribing doctor must request a medical exception.

The medications that have quantity limits are subject to change. Log in to Aetna Navigator. Then, select the Pharmacy Benefits Summary link and use the Medication Search to see which drugs have quantity limits.

The drug my doctor prescribed requires precertification, step-therapy or has quantity limits. How can I get an exception if necessary?
Depending on your plan, you may have to meet certain requirements before some drugs will be covered. These requirements include precertification, step therapy and quantity limits.

Your doctor may have prescribed a drug, which requires precertification, step therapy or quantity limits. In these cases, your doctor can ask for an exception to have the drug covered by your prescription benefits plan.

An exception is only given if the drug is medically necessary to treat your condition.
Aetna can work closely with your doctor to quickly review and potentially fulfill the request. We work with your doctor to collect and review medical information about your diagnosis. This includes applicable lab results, other drugs you may have tried for your condition and the results of you trying those drugs. 

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:
                             Aetna
                             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.