Pharmacy clinical policy bulletins

Aetna's Pharmacy Clinical Policy Bulletins (PCPBs) are used as a guide when determining health care coverage for our members with benefit plans covering outpatient prescription drugs. PCPBs are written on selected prescription drugs, primarily drugs on the Formulary Exclusion list, and drugs requiring Precertification or Step-Therapy. Actual clinical determinations in connection with coverage decisions are made on a case-by-case basis by Aetna. The PCPB is used as a tool to be interpreted in conjunction with the member's specific benefit plan and after consultation with the treating provider.

PCPBs can be highly technical and are designed to be used as a guide by our professional staff in making clinical determinations. Members and other consumers should review the information in our PCPBs with their treating physician or pharmacist so that they may more fully understand them.

We hope you find this information useful and welcome your feedback.

  
The Preferred Drug List
If a benefit plan covers outpatient prescription drugs, the plan may use a Preferred Drug List (formulary). A Preferred Drug List includes prescription drugs generally covered under the prescription drug benefit plan subject to applicable limits and conditions. The medications listed on the Preferred Drug List are subject to change in accordance with applicable law.* For information regarding how medications are reviewed and selected for the Preferred Drug List, please refer to to the Aetna Preferred Drug (Formulary) Guide. 

Information on the Preferred Drug List will be provided to members, if applicable, after enrollment and annually to current members and providers. This information is also available online through the Medication Search.

Customized information for members, according to their benefits, is available through Aetna Navigator™, our secure member website. Most drugs listed on the Preferred Drug List are subject to manufacturer volume discount arrangements under which Aetna receives financial consideration.

Prescription drug benefits are not limited to medications listed on the Preferred Drug List. Medications that are not listed on the Preferred Drug List may be covered subject to the limits and exclusions set forth in the member's plan documents, including but not limited to higher copayments, mandatory generic drug provisions (certain plans require the use of generics, when appropriate, for coverage), Precertification, Step-Therapy or Quantity Limits.

Precertification
Precertification helps encourage safe, cost-effective use of prescription drugs by requiring a "prior authorization" request from the member's physician before the drug will be covered.

Step-Therapy
Step-Therapy is a different form of Precertification, which requires a trial of one or more "prerequisite" medications before a "Step-Therapy" medication will be covered. If it is medically necessary for a member to use a Step-Therapy medication as initial therapy, the treating physician can request coverage of such drug as a medical exception.

Some prescription drug benefit plans (for example, closed formulary benefit plans) may exclude from coverage drugs listed on Aetna's Formulary Exclusions List. If it is medically necessary for members enrolled in these benefit plans to use such drugs, their physician (or pharmacist in the case of antibiotics or analgesics) can contact Aetna to request coverage as a medical exception.

Quantity Limits
Depending on the prescription plan chosen by the group's plan sponsor, certain medications may only be covered up to a certain quantity. In order to receive coverage for an additional amount of medication in excess of doses recommended by the Food and Drug Administration (FDA), the member's physician must obtain Precertification for the prescription from Aetna.

• This definition of Precertification is not the same as the definition used by Texas law. Our use of the term, "Precertification" relates to the prior authorization of your services by Aetna, based on our decision of whether the service is medically necessary. Precertification is not a guarantee of payment or "verification" as defined by Texas Law.
• For members in Texas, additions to the 2005 Preferred Drug list will be effective no later than January 1, 2005. In accordance with state law, full-risk members who are receiving coverage for medications that are removed from the Preferred Drug List during the plan year will continue to have those medications covered at the same benefit level, until their plan's renewal date.
• In accordance with state law, California HMO members enrolled in a closed formulary benefits plan who are receiving coverage for medications that are moved to the Formulary Exclusions List, and California HMO members who are receiving coverage for medications that are added to the Precertification or Step-Therapy Lists will continue to have those medications covered, for as long as the treating physician continues to prescribe them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee's medical condition.
• Nothing in this section shall preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this section be construed to prohibit generic substitution.
• Step-therapy, Precertification and Quantity Limits do not apply in all service areas. Precertification and Step-Therapy programs do not apply to fully-funded members in Indiana or Maine. Step-Therapy is not available for fully-funded groups in New Jersey. These programs are available to self-funded plans in New Jersey, Indiana and Maine. Members should refer to their plan documents or call the Member Services number on their ID card for further information.