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:
What is an example of precertification?
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:
What is an example of quantity limits?
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:
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:
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.
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.