Aetna Specialty CareRx

Aetna Specialty CareRx is a pharmacy benefit plan for certain specialty drugs. These are drugs that treat chronic health conditions (such as hemophilia, rheumatoid arthritis, multiple sclerosis and cancer).

Specialty drugs can be injected, infused or taken by mouth. They can be expensive. Retail pharmacies may not carry them. Some specialty drugs need to be refrigerated and delivered quickly.

Depending on your plan, you can find the drugs covered by your Aetna Specialty CareRx pharmacy benefit plan on one of these drug lists:

• 2013 Aetna Specialty CareRx – Self Injectables, Infused and Oral Drug List  (PDF, 672 KB) (Effective as of January 1, 2013)
• 2013 Aetna Specialty CareRx – Self Injectables Drug List  (PDF, 314 KB)
  (Effective as of January 1, 2013)

The names of these lists sound very similar. But there are important differences between them. This is especially true if you need specialty drugs that are taken by mouth or are given by infusion. (An infusion takes place when a liquid solution is introduced into the body through a vein, for example.)

If you have questions about which drug list applies to you, check your summary of coverage. Or, call the toll-free number on your member ID card. 

You may fill your first prescription for one of these drugs at a retail pharmacy. But to get the most from your coverage, you must order refills from an in-network specialty pharmacy, like Aetna Specialty Pharmacy.® (Aetna Specialty Pharmacy is a subsidiary of Aetna.)

(Some plans require you to get your refills through Aetna Specialty Pharmacy.) Please check your plan documents for more about the requirements and limitations of your pharmacy plan.

* In California: The entire Aetna Specialty CareRx program explained in this flyer does not apply if you are a member of a self-funded HMO plan.  If you aren’t sure what type of plan you have, check with your employer.  Or call Member Services at the toll-free number on your Aetna ID card.

** Specialty medications through Aetna Specialty Pharmacy and the Specialty Pharmacy Network may not be available to California HMO members.  Talk to your doctor about the appropriate way to get the specialty medications you need.  Doctors may have agreed to dispense and administer these drugs to you themselves.  Or they may write a prescription so you can fill them at any participating retail or mail-order pharmacy.


Support that matters

It is important to take your specialty drugs just how your doctor has prescribed. With Aetna Specialty Pharmacy, you get a personal care plan and the ongoing support you need when you take a specialty drug. This includes:

• registered nurses
• pharmacists
• care coordinators
• insurance and claims specialists.

With Aetna Specialty Pharmacy your out-of-pocket costs may be less, depending on your plan design. (All applicable copays apply.)

When you take a specialty drug, you should be monitored closely. There is a risk for side effects. A pharmacist or nurse should check in with you often during your treatment. Aetna Specialty Pharmacy offers you this type of support and more.

The drugs affected by Aetna Specialty CareRx are considered specialty drugs, as defined by Aetna. They are covered under you plan of benefits, as described in your summary of coverage. If you have questions, please call the toll-free number on your member ID card.

How to order your medicine

To save money, you need to get these drugs from a participating specialty pharmacy, like Aetna Specialty Pharmacy.

Your doctor can send in your prescription order. It’s easy and fast. You can order from Aetna Specialty Pharmacy by fax, mail or phone.

We deliver your medicines within 24 to 48 hours of confirming it. You and your doctor decide whether we send it to your home, your doctor’s office or any other location you choose. A package tracking program watches your order throughout the delivery process to make sure it arrives on time.

Or if you want your medicine a week after your order is confirmed, we can do that, too. If your prescription is missing information or if it requires precertification, this can impact your delivery time, even in urgent situations.

In emergency situations, please contact your doctor. If appropriate, Aetna Specialty Pharmacy has the ability to coordinate a same-day delivery. Or, they may be able to help you get a short-term supply of your medicine from a retail pharmacy near to you.

How we cover Aetna Specialty Care Rx Drugs

Your Aetna Pharmacy benefit plan will cover your specialty drug when:

• The prescription from your doctor is for a drug that is subject to the Aetna Specialty CareRx benefit guidelines. You or your caregiver(s) inject the drug

Your Aetna Medical benefit plan will cover your specialty drug when:

• You take a drug subject to the Aetna Specialty CareRx benefit design that your doctor gives you without a prescription
• Your doctor injects the drug for you

A plus sign (+) next to a drug's name on the Aetna Specialty CareRx drug lists means it's commonly given without a prescription or your doctor gave it to you directly.

Self-injectable drugs not subject to the Aetna Specialty CareRx drug lists are covered under your ordinary pharmacy benefit. They are subject to your pharmacy benefit’s appropriate copay, not your Aetna Specialty CareRx benefit.

Use our Price-A-Drug tool to check what you can expect to pay. Go to www.aetna.com and log into Aetna Navigator, your secure member website. Click Aetna Pharmacy and then Get Drug Prices.

Based on your prescription plan, you may have different copayments for brand and generic specialty drugs. This means you may pay different copay or co-insurance amounts.

Get the most from your specialty prescription drug coverage

To be sure you're drugs are covered:

• Get your specialty drugs from a participating specialty pharmacy, like Aetna Specialty Pharmacy.
• Some of the drugs on the Aetna Specialty CareRx – Self-Injectable Drug List and the Aetna Specialty CareRx – Self-Injectable, Infused and Oral Drug List have a plus sign (+) next to the drug name. If your doctor supplies and administers these drugs, he or she may continue to do so. You will not need to get refills through a specialty pharmacy. The drug will be covered under your medical plan. Depending on your medical plan, you may need to pay a copayment or coinsurance.
• Some of the drugs on the Aetna Specialty CareRx lists require precertification. This means they will not be covered unless your doctor asks us to approve this drug for you, and that your situation meets our criteria for using this drug. This applies to drugs that:
  • Are often taken in the wrong way
  • Should only be used for certain conditions
  • Often cost more than other drugs that are proven to be just as effective

You can find out if your drugs need precertification. Just search the Preferred Drug List. Please refer to your Summary of Coverage for specific information on pharmacy precertification requirements.

• Your coverage is not limited to drugs on this list.
• Please review your benefits plan for more detail.

Health benefits and health insurance plans are offered and/or underwritten by Aetna Health Inc. and/or Aetna Life Insurance Company (Aetna).  In Florida, by Aetna Health Inc. and/or Aetna Life Insurance Company.  In Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156.  Each insurer has sole financial responsibility for its own products.

Health benefits and health insurance plans contain exclusions and limitations.