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FAQS
Pharmacy Management Program - FAQ's for Providers
How do I become a participating provider in the Aetna pharmacy network?To request an enrollment packet, you may click on Online Enrollment Packet Request. You may also request an enrollment packet by fax or mail:
For fax or mail requests, please include the following information:Enrollment packets will be mailed within a week after receipt of your request. The entire enrollment process, including credentialing, usually takes approximately 4 weeks, provided we receive all the necessary information to process your request. Once your pharmacy has been approved for participation, a welcome packet will be mailed to your store. As soon as you receive your welcome packet, you may begin processing current prescriptions. 
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Whom do I call when I have questions regarding Aetna's prescription drug programs?Your first contact should always be with one of our Aetna Pharmacy Management Customer Service professionals. They can be reached using our toll-free line, 1-800-238-6279, and are available 24 hours a day, 7 days a week. Our Customer Service professionals can assist you with questions regarding claim processing, member eligibility, Maximum Allowable Cost (MAC List), Aetna's preferred drug list (also called a formulary), and other related issues.
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As a pharmacist, how can I support the Aetna preferred drug list (also called a formulary) and Precertification and Step-Therapy programs?As a pharmacist participating in our network, you play an important role in caring for Aetna members. When a member presents a prescription for a drug that requires precertification or prerequisite therapy or that is on the Formulary Exclusions List and may not be covered for some members, please intervene on his/her behalf by contacting the prescribing physician. If the physician wishes to request a medical exception so that a Formulary Exclusions List drug or step-therapy drug will be covered, direct him/her to the Aetna Pharmacy Management Precertification Unit. The physician can then fax the request to 1-800-408-2386 or can phone 1-800-414-2386 to request coverage. 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. In cases where a physician has prescribed an analgesic or antibiotic that requires medical exception or precertification, you may initiate the process by calling the Precertification Unit directly. If the Precertification Unit is closed, you may dispense one filling for an analgesic or antibiotic to an eligible Aetna member in accordance with the contracted rates. When the Precertification Unit reopens, you must call to receive authorization to transmit the claim online.
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What is the member ID number format?You will see member ID cards with numeric and alpha-numeric member numbers. In addition, there are Preferred Provider Organization (PPO) and Managed Choice (MC) plans that are social security number-based. It is a good idea to request to see the member ID card prior to filling any new prescription. If you should encounter any problems transmitting a claim, please call 1-888-792-8742 to speak with a Customer Service Professional. Our Customer Service Professionals are available 24 hours a day, 7 days a week to assist you.
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Do I need to enter a person code or group code when transmitting a claim?Neither a person code nor group number is required to process Aetna claims. However, if your particular computer system requires you to enter something in the group number field, please enter the default group number of 00670000.
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What BIN code do I use to process claims?All prescriptions submitted to Aetna for online adjudication must use BIN code 610502. Your software vendor will assist you with obtaining and installing/setting up the necessary software to submit claims online. If you have any problems or questions, please contact a Pharmacy Management customer service professional at 1-888-792-8742 for assistance 24 hours a day, 7 days a week.
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Does Aetna provide a public website for members and consumers?Yes. www.AetnaPharmacy.com helps members maximize their pharmacy benefits program by providing tools and resources to manage their health and reduce medication costs. The site features money-saving tips, interactive videos, a health-information encyclopedia, information on medications, generic drugs and drug safety; get well e-cards; a virtual herb garden; answers to frequently asked questions; information on how to refill medications through Aetna Rx Home Delivery® and much more more.
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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. |
