If a member needs a mail-order brochure and order form to submit for an initial supply of medication, they should call the toll-free Member Services number on their Aetna ID card.

After the initial form has been submitted, members can either call in refills using a toll-free phone number or mail a refill request. Members can also order refills via the Internet by accessing their mail-order provider’s website directly. Members who have Aetna Rx Home Delivery^® as their mail-order pharmacy can order refills or check the status of their order online by going to http://www.aetnarxhomedelivery.com. Members also can link to Aetna Rx Home Delivery by logging on to Aetna Navigator, Aetna’s self-service member website, through www.aetna.com. Members can also request refills by calling Aetna Rx Home Delivery at 1-866-612-3862.

Initial mail-order prescriptions cannot be ordered online. Generally, orders will be delivered, postage paid, by U.S. mail or another carrier within 14 days if they are “clean” and do not require intervention.

Formulary requirements vary depending on the prescription drug plan design. Prescription drug benefit plans with an open formulary cover all drugs, except contractually excluded drugs, with some plans requiring different copayments for generic, brand-name formulary and brand-name nonformulary drugs. Open formularies are available with Aetna PPO-based and indemnity pharmacy plans and HMO pharmacy plans, where filed and approved. In certain HMO service areas, plans are available with a closed formulary. Closed formulary plans do not cover a group of products listed in the Aetna Formulary Guide as Formulary Exclusions. A physician may request coverage for a drug on the Formulary Exclusions List by providing the Pharmacy Management Precertification Unit with clinical documentation supporting the drug’s medical necessity. Contractually excluded drugs are not covered under closed formulary plans as well.

Click here to link to the Preferred Drug list. Also available through that link is information on our Formulary Exclusions, Precertification and Step-Therapy lists. For more formulary-related questions and answers, please refer to the Formulary FAQs.

To learn about Pharmacy Management’s guidelines for determining health care coverage for selected outpatient prescription drugs on the Formulary Exclusions List or those drugs requiring precertification or step-therapy, see our Pharmacy Clinical Policy Bulletins.

Prospective Review

In most plans, we require precertification of certain drugs to help encourage appropriate prescribing in accordance with generally acceptable guidelines. Drugs requiring precertification have a narrowly defined use and present a greater possibility for inappropriate use. Criteria are based on FDA, manufacturer labeling and peer-reviewed medical information.

Physicians can call us toll-free or fax us to request precertification. When the physician calls, we generally attempt to approve or deny requests during the call.

Concurrent Review Concurrent drug utilization review helps promote appropriate dispensing and use of drugs that is consistent with established pharmaceutical guidelines. Prescriptions filled at participating pharmacies are automatically screened against the member's available drug history. Examples of standard concurrent online edits available for claims submitted online include:

• Too-Early Refill – System denies reimbursement for a refill prescription before a predetermined percentage of the days supply has been used.
• Exact Duplicate – The system prohibits reimbursement for the exact drug name, strength and date of service.
• Step-Therapy – Therapeutically equivalent “first-line” medications must be tried initially before claims for “second-line” therapies will be covered.
• Drug Gender – The pharmacist is notified when a prescription claim is inappropriate for the member's gender.
• Geriatric and Pediatric Minimum/Maximum Dosing – Informational edits alert the pharmacist when a prescribed dose is over or under the recommended dosage for individuals over age 65 or under age 12.
• Minimum and Maximum Dosing – Informational edits notify the pharmacist when drug dosing is over/under the clinically appropriate limit based on quantity and days supply.
• Formulary Drug – In closed formulary plans, the system denies reimbursement for Formulary Exclusions unless a medical exception is first obtained.
• Duplicate Therapy – Informational edit notifies the pharmacist when a new prescription duplicates the therapy of another drug the member is taking.
• Drug/Drug Interaction – The pharmacist is notified if a drug may cause complications when taken with drug(s) the member is already taking.
• Side Effects – The system notifies the pharmacist of possible side effects such as drowsiness or an upset stomach.
• Drug-to-Disease Interaction – Using stored codes for 14 different diseases, the system screens for drugs that are contraindicated for members with certain existing medical conditions.
• Drug-to-Disease by Proxy – The system screens for drugs contraindicated for members with certain existing medical conditions, such as asthma and diabetes, based on the member's available drug history.
• Underutilization – Based on the days supply that the pharmacy enters for the initial prescription, the system notifies the pharmacy when the patient's refill pattern is aberrant or falls under the effective dose therapy.
• Drug-Pregnancy/Lactation – System will screen for drugs contraindicated in pregnancy and lactation.
• Drug Allergy – By using stored member allergy information, the system can perform drug allergy screenings.

Retrospective Review

Retrospective review of pharmacy claims is performed to accomplish the following:

• Measure the quality and appropriateness of primary care physician prescribing based on accepted guidelines through Formulary Compliance Reports.
• Provide physician drug information programs to help promote appropriate, cost-effective prescribing and drug therapies.
• Help providers identify asthmatic plan members who are at risk for an acute asthma attack and provide the appropriate intervention.
• Provide vital plan-specific utilization and financial information through Quarterly Pharmacy Utilization Reports.