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Pharmacy Clinical Policy Bulletins

Guides for prescription drug coverage

These guides help us make coverage decisions for members whose plans cover outpatient prescription drugs. They explain what drugs will and will not be covered. These bulletins are highly technical and meant to be used by health care professionals making treatment decisions.

Pharmacy Clinical Policy Bulletins primarily cover drugs that:

  • Are on our Preferred Drug List
  • Require precertification or step therapy

Aetna Commercial (non-Medicare) Prescription Drug Plans

Search Pharmacy Clinical Policy Bulletins (PCPBs)

 
 
 
 

Aetna Medicare prescription drug plans

We also provide information about our Medicare prescription drug plans.

See this information

Health insurance exchange prescription drug plans

Find information about prescription drug plans offered on public exchanges.

Individual prior authorization criteria
Individual step-therapy criteria
Small group prior authorization criteria
Small group step-therapy criteria

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Clinical Policy Bulletins

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  • Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. Treating providers are solely responsible for dental advice and treatment of members. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider.
  • While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). Your benefits plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government.
  • Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change.
  • Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies.
  • Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met.
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