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Pharmacy Transition of Coverage Information
Thank you for enrolling in an Aetna® pharmacy benefits plan. If the pharmacy benefits plan your are enrolled in includes a formulary, the following tips will help facilitate a smooth transition:*
- If you are a new Aetna member, you may have different requirements regarding coverage for prescription drugs under your new benefit plan. For instance, a drug previously covered under your former health plan may not be covered under your Aetna benefit plan. Please refer to your Aetna plan documents or call the Member Services number on your ID card or 1-800-323-9930 for information regarding the terms and conditions of your new benefit plan.
- If you're renewing with Aetna, you may also find different requirements in place regarding drug coverage under your new benefit plan. This is especially true if you're moving from a plan that has an open formulary to one that has a closed formulary. (The key difference between an open and closed formulary is that drugs on our Formulary Exclusions List are not covered for members in a closed formulary benefits plan unless a medical exception is obtained.) Or, certain medications may be subject to prior approval, meaning they must meet our precertification or step-therapy program requirements, before they will be covered under your new benefit plan. Please refer to your Aetna plan documents or call the Member Services number on your ID card or 1-800-323-9930 for information regarding the terms and conditions of your new benefit plan.
- If the drug you are currently taking requires a medical exception or precertification before it will be covered under your new plan, your provider will need to submit a medical exception or precertification request to the Aetna Pharmacy Management Precertification Unit. If your medication is subject to step-therapy, you will need to comply with applicable step-therapy program requirements for coverage. However, if it is medically necessary for you to be initially treated with a drug subject to step-therapy, your provider can contact our Pharmacy Management Precertification Unit to request coverage as a medical exception.
We wish you good health.
Question: How do I know if the drug I'm currently taking is on the 2003 Formulary Exclusions, Precertification or Step-Therapy Lists?
Answer: Please consult the Medication Search option and complete the necessary steps to determine if the drug you are taking is on any of these lists. Or, call the Member Services number on your ID card or 1-800-323-9930. For more information regarding these lists and how they may apply under your benefit plan, refer to your plan documents or call Member Services.
Note: Members enrolled in PPO-based benefit plans should call Member Services for information regarding which medications may require precertification.
Question: How does my provider request approval for continuing coverage of a drug on the Formulary Exclusions List or for a drug that requires precertification or step-therapy?
Answer: If you are enrolled in a closed formulary benefit plan, or are enrolled in a plan that includes precertification or step-therapy, have your provider complete the Medical Exception/ Precertification Request Form and fax it to the Aetna Pharmacy Management Precertification Unit at 1-800-408-2386, preferably before the effective date of your new pharmacy benefit plan. The Precertification Unit will review the request to determine whether you meet the necessary criteria for coverage. Please refer to the Pharmacy Clinical Policy Bulletins, which identify the clinical criteria for drugs subject to precertification, step-therapy or quantity limits. These bulletins also provide information about the medical exception criteria for drugs on our Formulary Exclusions List.
Question: How long will it take the Precertification Unit to review my provider's request?
Answer: Once your new pharmacy plan eligibility information is entered into our pharmacy claims system, it generally takes 24 to 48 hours (or as required by law) for the Precertification Unit to respond to a complete request.
Question: How will I know if my provider's request has been approved?
Answer: The Precertification Unit will notify your provider by fax whether the request has been approved or denied. If the request is denied, you and your provider also will receive a letter of denial.
Note: For members in Texas, the January 2003 formulary will be effective upon their plan's renewal date in 2003. In accordance with state law, members who are receiving coverage for medications that are removed from the formulary during the plan year will continue to have those medications covered at the same benefit level, until their plan's renewal date.
*This information applies to HMO-based benefit plans and Golden Medicare Plans™. This information does not apply to California HMO members. 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 along as the treating physician continues to prescribe the medication.
Note: For members in Texas, the January 2003 formulary will be effective upon their plan's renewal date in 2003. In accordance with state law, members who are receiving coverage for medications that are removed from the formulary during the plan year will continue to have those medications covered at the same benefit level, until their plan's renewal date.
To contact your Member Services office by phone, please call the toll-free number listed on your ID card. If you do not have an ID card yet, please contact your employer's benefits office to obtain this toll-free number.
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