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General FAQs
We offer a single national pharmacy network that provides members with access to over 67,000 pharmacies located in 50 states, the District of Columbia, Puerto Rico and the Virgin Islands. The network includes 82% of the independent and chain pharmacies in the country. You can find participating pharmacies on our secure member site or by calling Member Services at the toll-free phone number on your Member ID card.
Yes. Aetna provides a single, toll-free telephone number that members can call for both medical and pharmacy benefit questions. In addition, each mail-order vendor provides a toll-free customer service line for members to check the status of their orders, request prescription refills or speak with a pharmacist about their medications.
Plan members receive an enrollment kit that includes the order forms and envelopes they need to request covered prescription drugs via mail-order delivery (where mail-order is available). To order a drug, the member completes an enrollment form and submits the profile information (with the first order only) and the original prescription(s) in the pre-addressed envelope. The member must include a check for the appropriate copayment(s) or provide a credit card number.
If a member needs a mail-order brochure and order form to submit for an initial supply of medication, they should call the toll-free Member Services number on their Member ID card.
After the initial form has been submitted, members can either call in refills using a toll-free phone number or mail a refill request. Members can also order refills via the Internet by accessing their mail-order provider’s website directly. Members who have CVS Caremark® Mail Service Pharmacy as their mail-order pharmacy can order refills or check the status of their order online. Members can link to CVS Caremark Mail Service Pharmacy by logging on to Aetna’s self-service secure member website. Members can also request refills by calling CVS Caremark Mail Service Pharmacy directly.
Generally, orders will be delivered, postage paid, by U.S. mail or another carrier within 14 days if they are "clean" and do not require intervention.
Aetna uses a preferred drug list of effective and affordable drugs approved by the U.S. Food and Drug Administration. In selecting drugs for this list, Aetna focuses first on quality before considering cost. Many drugs on the preferred drug list are subject to rebate arrangements between Aetna and the manufacturer of those drugs.
Formulary requirements vary depending on the prescription drug plan design. Prescription drug benefit plans with an open formulary cover all drugs, except contractually excluded drugs, with some plans requiring different copayments for generic, brand-name formulary and brand-name nonformulary drugs. Open formularies are available with Aetna PPO-based and indemnity pharmacy plans and HMO pharmacy plans, where filed and approved. In certain HMO service areas, plans are available with a closed formulary. Closed formulary plans do not cover a group of products listed in the Aetna Formulary Guide as Formulary Exclusions. A physician may request coverage for a drug on the Formulary Exclusions List by providing the Pharmacy Management Precertification Unit with clinical documentation supporting the drug’s medical necessity. Contractually excluded drugs are not covered under closed formulary plans as well.
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.
Yes.
Prospective Review
In most plans, we require precertification of certain drugs to help encourage appropriate prescribing in accordance with generally acceptable guidelines. Drugs requiring precertification have a narrowly defined use and present a greater possibility for inappropriate use. Criteria are based on FDA, manufacturer labeling and peer-reviewed medical information.
Physicians can call us toll-free or fax us to request precertification. When the physician calls, we generally attempt to approve or deny requests during the call.
Concurrent Review
Concurrent drug utilization review helps promote appropriate dispensing and use of drugs that is consistent with established pharmaceutical guidelines. Prescriptions filled at participating pharmacies are automatically screened against the member's available drug history. Examples of standard concurrent online edits available for claims submitted online include:
- Too-early refill – System denies reimbursement for a refill prescription before a predetermined percentage of the days supply has been used.
- Exact duplicate – The system prohibits reimbursement for the exact drug name, strength and date of service.
- Step-therapy – Therapeutically equivalent “first-line” medications must be tried initially before claims for “second-line” therapies will be covered.
- Drug gender – The pharmacist is notified when a prescription claim is inappropriate for the member's gender.
- Geriatric and pediatric minimum and maximum dosing – Informational edits alert the pharmacist when a prescribed dose is over or under the recommended dosage for individuals over age 65 or under age 12.
- Minimum and maximum dosing – Informational edits notify the pharmacist when drug dosing is over/under the clinically appropriate limit based on quantity and days supply.
- Formulary drug – In closed formulary plans, the system denies reimbursement for Formulary Exclusions unless a medical exception is first obtained.
- Duplicate therapy – Informational edit notifies the pharmacist when a new prescription duplicates the therapy of another drug the member is taking.
- Drug and drug interaction – The pharmacist is notified if a drug may cause complications when taken with drug(s) the member is already taking.
- Side effects – The system notifies the pharmacist of possible side effects such as drowsiness or an upset stomach.
- Drug-to-disease by proxy – The system screens for drugs contraindicated for members with certain existing medical conditions, such as asthma and diabetes, based on the member's available drug history.
- Underutilization – Based on the days supply that the pharmacy enters for the initial prescription, the system notifies the pharmacy when the patient's refill pattern is aberrant or falls under the effective dose therapy.
- Drug-pregnancy and lactation – System will screen for drugs contraindicated in pregnancy and lactation.
- Drug allergy – By using stored member allergy information, the system can perform drug allergy screenings.
Retrospective Review
Retrospective review of pharmacy claims is performed to accomplish the following:
- Measure the quality and appropriateness of primary care physician prescribing based on accepted guidelines through Formulary Compliance Reports.
- Provide physician drug information programs to help promote appropriate, cost-effective prescribing and drug therapies.
- Help providers identify asthmatic plan members who are at risk for an acute asthma attack and provide the appropriate intervention.
- Provide vital plan-specific utilization and financial information through Quarterly Pharmacy Utilization Reports.
We offer multiple plan design options for our customers encompassing a variety of plan provisions. As a result, group contracts vary by customer. However, a plan administrator may opt to offer several different plans to provide choices for their members. If more than one option is available, members can select a benefits plan that includes or excludes prescription coverage. Once a member selects a plan, coverage is provided as a package.
The Centers for Medicare and Medicaid Services (CMS) provide general information to employers about Medicare Part D Creditable Coverage requirements and model disclosure notices.
Legal notices
Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).
Health benefits and health insurance plans contain exclusions and limitations.
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 the back of 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.