How We Cover Drugs

Drug reviews can determine what you’ll pay

Before your plan covers a drug, it may need a special review*. These reviews can help you and your doctor find safe drugs and keep your costs low.

To decide which drugs need these reviews, we look at manufacturer labeling, treatment guidelines and dosing approved by the U.S. Food and Drug Administration (FDA).

Precertification**

We may have to approve some drugs before your pharmacy benefits and insurance plan covers them. This is for drugs that:

  • Are often taken the wrong way
  • Should only be used for certain conditions
  • Often cost more than other drugs proven just as effective

Your doctor must contact us for precertification approval. We'll tell your doctor if we approve the request. If you live in a state where notification is required, we will alert you as well. We'll cover the medicine according to the copay your plan has.

If we don't cover the drug, you can still buy it. However, you will need to pay the full price. Instead, talk to your doctor to see if there may be another drug that is right for you that will be covered by your plan.

Step therapy

Some drugs are covered only after your doctor prescribes one or more alternative drugs first. The other drug works the same and treats the same condition. But it may cost less.

Quantity limits

Some drugs have a limit on how many doses your doctor can prescribe for you. This helps make sure you get a safe amount of your drug. This is for drugs that:

  • Are often taken the wrong way
  • Are often taken in amounts greater than the recommended dose

Find out if your drug is affected by drug coverage reviews

Log in to Aetna Navigator®, your secure member website for a list of drugs that need reviews. Follow these steps:

1

Select "Aetna Pharmacy" from the top of the page

2

Go to the "Your Drug Coverage" section, select "Medication Search" and enter your plan type.

Try our Price-A-DrugSM tool

Check what you can expect to pay for a drug based on your plan.

  • Compare the costs of generic and brand-name drugs.
  • Estimate the cost of a prescription drug from your local retail pharmacy or a mail-order pharmacy.
  • Check how much money you can save. Remember that cheaper does not mean lower quality.

Log in to Aetna Navigator. Then follow these steps:

1

Click "Aetna Pharmacy" from the top of the page.

2

Then click "Get Drug Prices."

*The drugs that require these reviews are determined based on manufacturer labeling, accepted treatment guidelines and dosing approved by the Food and Drug Administration (FDA).

**In Texas, this approval is known as “pre-service utilization review.” It is not “verification” as defined by Texas law.

This material is for information only.  These drug coverage review programs may not apply in all service areas and all plans. Refer to your plan documents or call Member Services with any questions. For example, precertification, step therapy and quantity limits do not apply to fully insured HMO members in Indiana. Step therapy is also not available to fully insured members in New Jersey. However, these programs are available to self-funded plans in New Jersey and Indiana.

This material is for information only.  These drug coverage review programs may not apply in all service areas and all plans. Refer to your plan documents or call Member Services with any questions. For example, precertification, step therapy and quantity limits do not apply to fully insured HMO members in Indiana. Step therapy is also not available to fully insured members in New Jersey. However, these programs are available to self-funded plans in New Jersey and Indiana.

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