Pharmacy Management Program - FAQ's for Members


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	Pharmacy Management Program - FAQ's for Members How do I know which pharmacies in my area participate in the Aetna pharmacy network? What is the difference between generic and brand name drugs and how does that difference affect my benefits? Why are brand-name drugs more expensive? How do I know a generic drug is the same as a brand-name drug? Can a person be allergic to a generic and not a brand-name drug? What is the benefit of obtaining my medications through mail-order? How do I get covered prescriptions filled through a mail-order pharmacy? Can I order my mail-order refills through the Internet? What is a preferred drug list (also called a formulary), and does that affect me? Can I get reimbursed for drugs I got from a pharmacy not in the network? How can I find out about my copayment, drug coverage, maximum drug allowance and other benefits? How can I obtain information about a specific drug? If I am going to be out of town for an extended time, how do I get an extra supply of drugs to cover me through that period? Why do I pay an amount different from my copayment for some drugs? Are diabetic supplies covered under my pharmacy benefit? What can I do to prevent a medication error? How do I get a list of preferred drugs (formulary information)? How does Aetna define preventive medications, and how did Aetna determine the list of preventive medications? How can I view the preventive medication list? How does Aetna define chronic medications, and how did Aetna determine the list of chronic medications? How can I view the chronic medication list? How do the preventive and chronic medication lists apply to my plan? How do I request a medical exception? Why do some medications have quantity limits? How do I know which pharmacies in my area participate in the Aetna pharmacy network? You can search for a participating pharmacy in our network online using DocFind®, our online provider directory. You can search for a pharmacy by zip code, by pharmacy name, by pharmacy benefit plan or program, or by the number of miles from your home you want to travel. You may also contact the toll-free Member Services telephone number on your ID Card for assistance in locating a participating pharmacy in your area. Availability varies by service area. What is the difference between generic and brand name drugs and how does that difference affect my benefits? The only significant difference between a brand-name drug and a generic drug is the price. Brand-name drugs are more expensive. In fact, the use of generic drugs has become a very valuable tool in helping to reduce overall prescription drug costs without sacrificing quality. Generic drugs make good economic sense for Aetna members because under many of our prescription drug benefit plans, generic drugs have a lower copayment. So, depending on your benefit plan design, you get a therapeutically equivalent drug for less money. Your employer may also realize a reduction in claim costs when you use generic drugs. Why are brand-name drugs more expensive? Brand-name drugs are more expensive than generics because the manufacturers have spent years on research and clinical studies in developing a new medication. As a result, drug manufacturers look to recover some of these research and development costs through drug pricing strategies. Because there are no drug price controls, manufacturers can set the price of their drug at whatever level they want. However, once a patent on a brand-name drug expires, generic manufacturers may produce an equivalent generic drug. Because generic drug manufacturers are not introducing a new drug, they avoid the related expenses associated with developing a new medication, which is reflected in the lower price. How do I know a generic drug is the same as a brand-name drug? There are many myths and misconceptions about generic drugs. Some people believe that quality is tied to costs, and that a less expensive product is of lower quality. In the case of generic drugs, that is simply not true. A generic drug can be produced once the brand-name drug patent has expired. However, the Food and Drug Administration (FDA), which approves brand-name drugs, must also approve all generic drugs before they can be sold. To gain approval by the FDA, a generic drug must: contain the same active ingredients in the same amounts as the brand-name drug. be identical to the brand-name product in dosage form and in the way it's administered. For instance, if a brand-name drug is a tablet taken by mouth, the generic must also be a tablet taken by mouth. have the same uses, cautions, warnings and product labeling as the brand-name drug. have absorption rates that closely match that of the brand-name product. In other words, the time it takes for the body to absorb the generic drug and the amount absorbed at a given time interval must be nearly identical to the brand-name drug. meet batch consistency requirements for identity, strength, purity and quality. Each batch of the generic drug must be identical in every way to all other batches of the generic and brand-name product. Can a person be allergic to a generic and not a brand-name drug? A generic drug must contain the same active ingredients in the same amounts as the brand-name drug. However, the inactive ingredients, as well as the color or shape of a generic drug, may be different from its brand-name counterpart. Individuals who are experiencing a “reaction” to a particular generic drug may be allergic or sensitive to these inactive ingredients or dyes. Switching to another product from a different generic manufacturer may relieve the problem. *What is the benefit of obtaining my medications through mail-order?** Ordering your medications by mail is convenient, saves time and may even save you money. Our pharmacy plans offer mail-order delivery of covered medications in excess of a 30- or 34-day supply, depending on the plan design.. Medications are delivered directly to your home or office within a few days or overnight, if needed. Depending on your plan design, mail-order delivery may save you money, too. If you currently receive a one-month supply of your medication at a retail pharmacy, you may pay three copayments under your plan over a 90-day period. However, if you use the mail-order service, you can get a three-month supply at once and pay only one or two copayments, depending on your plan design. So, you receive three times the medication for no more than two copayments. There is no additional charge for using the mail-order service, other than the copayment(s). If you request overnight delivery, you will be charged an additional amount accordingly. You may also see additional savings if you request generic medications. * Certain states require that prescriptions for more than a 30-day supply be available through a participating retail or mail-order pharmacy for the same copay. Please consult your benefit plan documents for details. How do I get covered prescriptions filled through a mail-order pharmacy? If you are a first-time user of your mail-order benefit, you must complete an enrollment form and submit this information and your original prescription(s) to the mail-order vendor. You must include a check for the appropriate copayment(s) or provide a credit card number. Be sure your physician has specified a 90-day supply on your prescription. After the initial form has been submitted, ordering refills is easy. You can call in refills using a toll-free phone number, mail a refill request or order a refill via the Internet (see Question 8). Once the mail-order facility receives your prescription request, it will be processed using Aetna’s claims processing system, which is also used at all participating retail pharmacies. Generally, prescription orders are processed and shipped from the facility via U.S. mail within two business days of receipt if they are "clean" and do not require intervention. When requesting medications by mail, make sure you order a refill about 14 days before your medicine runs out, to allow sufficient time for processing and shipping. Keep in mind there is an additional expense for overnight delivery of medications, and this will be charged to you. If you have questions about mail order or need a mail-order registration kit, please call the Member Services toll-free number on your Aetna ID card. Can I order my mail-order refills through the Internet? Yes. If your mail-order pharmacy is Aetna Rx Home Delivery^® and you obtained your initial prescription from this facility, you can order refills online by logging in to Aetna Navigator, Aetna’s self-service member website, and then select “Your Pharmacy Benefits Summary/Mail-Order Pharmacy/Aetna Rx Home Delivery.” If your mail-order pharmacy was recently changed to Aetna Rx Home Delivery and you obtained your initial prescription from a different mail-order pharmacy (Express Scripts, Inc., Wal-Mart, Walgreens, etc), please do the following: Call Aetna Rx Home Delivery toll-free at 1-866-612-3862 and give the refill prescription number to the customer service representative. The representative will then give you a new Aetna Rx Home Delivery refill number and will refill your prescription. Subsequent refills can be ordered online. Please remember, initial mail-order prescriptions cannot be ordered online. If you need a mail-order brochure and order form to submit for your initial supply of medication, please log in to Aetna Navigator, Aetna’s self-service member website, and then select “Your Pharmacy Benefits Summary/Mail-Order Pharmacy/Aetna Rx Home Delivery” or call the Member Services number on your Aetna ID card. What is a preferred drug list (also called a formulary), and does that affect me? 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. Can I get reimbursed for drugs I got from a pharmacy not in the network? Whenever possible you should try to use one of the more than 51,000 Aetna participating pharmacies. If, however, you use a non-participating pharmacy, you will be required to pay the full cost of your prescription and will need to submit a Prescription Drug Claim Form to Aetna for reimbursement. Please remember that reimbursement is dependent upon your pharmacy plan, and may be subject to certain limitations and restrictions. You should refer either to your Certificate of Coverage or Benefits Booklet for details, or you may contact a Member Services representative by calling the toll-free number on your ID card. If you do not have an ID card yet, please contact your employer's benefit office. To submit a claim for reimbursement, please follow the steps below: The following documents are provided in Adobe PDF format. Print and complete the Prescription Drug Claim form (PDF: 359 KB / 2 pages) Print and complete the Medicare Prescription Drug Claim form (PDF: 326 KB / 2 pages) Obtain receipt(s) for all prescription(s) paid out-of-pocket Receipt(s) must have a legible member ID number Receipt(s) must be submitted within two years of the date of purchase Mail receipt(s) and claim form to: Aetna Pharmacy Management Attn. Claim Processing PO Box 398106 Minneapolis, MN 55439 To maximize the value and convenience of your prescription drug benefits, please use a participating pharmacy whenever possible. By presenting your Aetna member ID card at a participating pharmacy, you can save time and incur lower out-of-pocket expenses. All you need to do is: Take your prescription to any of the more than 51,000 plus pharmacies that participate in our national network. Present your member ID card at the pharmacy. This will identify you as an Aetna member. With your ID number, the pharmacy will be able to submit your claim to us electronically at the time your prescription is filled. You pay the pharmacy only a copayment determined by your benefits plan. There's no need to submit a claim form to Aetna for reimbursement. Your claim has already been processed! How can I find out about my copayment, drug coverage, maximum drug allowance and other benefits? Information regarding your benefits may be found in your Certificate of Coverage and other plan documents. In addition, a Member Services representative can provide you with information on copayment amounts, drug coverage, maximum drug allowance, deductible amounts and other aspects of your prescription drug benefits, including limitations and restrictions. You can reach a Member Services representative by calling the toll-free number on your ID card. How can I obtain information about a specific drug? Your physician or pharmacist can provide you with detailed information regarding specific medications. In addition, you can access drug information from Aetna InteliHealth^SM (www.intelihealth.com), Aetna's online health information affiliate, which features a comprehensive collection of consumer health information. If I am going to be out of town for an extended time, how do I get an extra supply of drugs to cover me through that period? If a prescription refill is due while you are away on vacation, you can request an additional supply of medication prior to your departure. The request should be made to the Aetna participating pharmacy that filled the original prescription. Members are responsible for any additional copayments if their request for medication is for an extended period of time. Please keep in mind that prescriptions can be filled at any Aetna participating pharmacy in our network throughout the country. If you wish to take advantage of this convenience, you do not need to obtain a vacation supply before leaving on vacation; however you need to request a new prescription from your physician to present to the participating pharmacy at your vacation destination. Why do I pay an amount different from my copayment for some drugs? Depending on your plan design, you may be required to pay an amount different from your copay if: You or your doctor request a brand-name drug when a generic drug is available and your plan design requires you to use the generic drug. You will pay your copayment plus the difference in cost between the brand-name and generic drug. Your plan design has a feature that allows the doctor to request a brand-name drug when a generic drug is available as long as the doctor writes Dispense As Written (DAW) on the prescription. If the doctor doesn't write DAW, then you will pay your copayment plus the difference in cost between the brand-name and generic drug. For more detailed information, please review your benefit plan, check with your employee benefits contact or call the toll-free number on your ID card to reach an Aetna Member Services representative. Are diabetic supplies covered under my pharmacy benefit? All pharmacy plans (HMO and non-HMO) cover insulin. Other diabetic supplies may be covered depending upon the particular benefit package purchased by your employer or as mandated by the laws in your state. What can I do to prevent a medication error? Click here for specific steps you can take as a consumer to help prevent a medication error. How do I get a list of preferred drugs (formulary information)? Members can obtain formulary information from the Internet at , or, by calling our Member Services toll-free number. How does Aetna define preventive medications, and how did Aetna determine the list of preventive medications ? Preventive medications are generally prescribed for individuals who may be at risk for certain diseases or conditions but who are not yet showing signs of that disease or condition. Preventive care does not include drugs or medicines for treatment of an existing illness or condition. Preventive medications are used to prevent: a disease or condition; complications from a disease; or the reoccurrence of a condition. Examples of such diseases and conditions include: Hypertension (high blood pressure) and the prevention of conditions related to hypertension Hyperlipidemia (high cholesterol) and the prevention of heart disease Diabetes and the prevention of diabetic complications Asthma and the prevention of asthmatic episodes Osteoporosis and the prevention of conditions resulting from osteoporosis Prevention of stroke Prevention of various pediatric conditions, such as vitamins and fluoride deficiency Prevention of maternal and fetal problems during pregnancy The drug classes included in the program are antihypertensives including beta-blockers, calcium channel blockers, and ACE inhibitors; diuretics; anti-hyperlipidemics; anti-diabetics; anti-asthmatic agents; anti-osteoporosis medications; anticoagulants; platelet aggregation inhibitors; pediatric vitamins with fluoride; prenatal multivitamins with iron and folic acid. We selected classes of drugs that are substantially used for preventive purposes and are associated with several highly prevalent conditions. Individuals with these conditions can be relatively symptom free if the condition is managed effectively, while failure to manage these conditions can result in serious illness or injury. How can I view the preventive medication list? View the preventive medication list. How does Aetna define chronic medications, and how did Aetna determine the list of chronic medications? Chronic medications are used to treat an ongoing condition (that has been diagnosed) regardless of the risk for complications and for which an individual may be currently experiencing symptoms. Chronic medications are drugs used in the treatment of chronic conditions, such as: Hypertension Hyperlipidemia Diabetes Depression Heart disease Asthma Heart failure Psychotic disorders such as schizophrenia or bipolar disorder We selected several classes of drugs that are substantially used for treatment of highly prevalent chronic conditions. Individuals with these conditions can be relatively symptom free if the condition is managed effectively, while failure to manage these conditions can result in serious illness or injury. How can I view the chronic medication list? View the chronic medication list. How do the preventive and chronic medication lists apply to my plan? The preventive and chronic medication lists are available as an option for plan sponsors who do not want to apply a deductible to these medications. Please contact your employer if you have questions about what your plan covers. How do I request a medical exception? The quickest way to request an exception is to contact your doctor and request that he or she sends in the information requested on the RX Medical Exception/Precertification Request Form to Aetna Pharmacy Management for review. Why do some medications have quantity limits? Quantity limits are included as part of our precertification program and are designed to help promote appropriate and efficient medication use and enhance patient safety. Quantity limits are based on generally accepted pharmaceutical guidelines, efficient dosing regimens and dosing recommendations. There are three types of quantity limits: Dose Efficiency Edits - Limits coverage of prescriptions to one dose per day for drugs that are approved for once-daily dosing. Maximum Daily Dose - Informational message is sent to the pharmacy if prescription lies outside recommended minimum and maximum doses. 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 in excess of the quantity listed, the prescribing physician must request a medical exception. The medications that have quantity limits are subject to change. You can use our Aetna Medication Search online which includes drugs with Quantity Limits. Once you select your plan type, you will see the link to the Medicare Search page. This is a brief summary of certain general aspects of Aetna pharmacy coverage, which vary by specific service are and plan of benefits. Certain plans do not cover prescription drugs which are not on the Aetna formulary or cover such drugs with a higher copayment. Formulary information is available on the website or by calling the number on your member ID card. This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan or program benefits and does not constitute a contract. Consult your plan documents (Schedule of Benefits, Certificate of Coverage, Group Agreement, Group Insurance Certificate, Booklet, Booklet-certificate, Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitations relation to your plan. All the terms and conditions of your plan or program are subject to applicable laws, regulations and policies. The availability of a plan or program may vary by geographic service area. All benefits are subject to coordination of benefits. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change without notice. HMO, QPOS® and USAccess® referred benefits may be provided or administered by: Aetna Health Inc., Aetna, Aetna Health of California Inc., Aetna Health of the Carolinas Inc., Aetna Health of Illinois Inc., QPOS and USAccess referred benefits may be provided or administered by Aetna Health of Washington Inc.; QPOS and USAccess self-referred benefits may be provided or administered by: Aetna Health of the Carolinas Inc., Aetna Health of Washington Inc., Aetna Life Insurance Company, Aetna Health Insurance Company of Connecticut, and/or Aetna Health Insurance Company. Benefits are provided or administered by Aetna Life Insurance Company for Managed Choice® POS, Open Choice® PPO and Traditional Choice® indemnity plan, including life insurance coverage. Elect Choice® benefits are employer-funded and are administered by Aetna Life Insurance Company.

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