Skip to main content

Pharmacy FAQs

Choose a category below to see questions and answers about pharmacy coverage.

 

GO TO:


Automatic Refill Program

When you enroll qualified prescriptions into the program, we will automatically refill and ship your prescriptions to you at the appropriate time. We will also contact your doctor to renew an enrolled prescription before the last refill or the prescription is about to expire.
 

You can select which prescriptions to have filled automatically. Not all prescriptions may be eligible for the service, however. Jump to more information about prescription eligibility.
 

When you enroll a prescription in the service, you will need to select a preferred method of communication (either automated phone call, email or text message) to receive notices about upcoming automatic refill orders. If you select automated phone calls or text messages, please note that you may also receive notices by email or the U.S. postal mail.

There is no cost to participate in the Automatic Refill program. Your refills will be mailed to you before you run out of medication, without any service, shipping or handling charges. Unless you cancel the order, your co-pay or coinsurance costs will be charged when your order ships.
 

If expedited shipping is requested, charges may apply.
 

Copayment, co-pay or coinsurance is the amount a plan member is required to pay for a prescription in accordance with a plan. The amount may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with a balance, if any, paid by a plan.

You won’t have to remind yourself to refill your mail order prescriptions. We’ll take care of that for you. It also helps ensure that you have enough medication on hand to take as instructed by your doctor. Doing so will help you stay healthier and avoid costly emergency room visits and hospital stays. (Andrew M. Peterson, and others. American Journal of Health-System Pharmacy, Volume 60, Issue 7, 1 April 2003, Pages 657-665.)

Create an online account or log in to an existing account and select the eligible prescriptions you want to enroll. You can also call the number on your member ID card and we’ll take care of enrolling your prescriptions into the program for you.

No, not all prescriptions are eligible for automatic refills. The service is available for many common maintenance medications taken for long-term therapy, such as medications for managing high blood pressure, high cholesterol and diabetes.
 

Medications such as controlled substances, specialty drugs and prescriptions covered by certain government payers, including Medicare Part B, are not eligible.

To see which of your prescriptions qualify for automatic refills, log in to your online account or call the number on your member ID card to speak with a Customer Care agent.

When you enroll a prescription, you can select how you want to be notified about upcoming automatic refill orders. Choose from automated phone calls, emails or text messages. If you select automated phone calls or text messages, please note that you may also receive notices by email or US Postal Service.

Here's how the service works:

  • Enroll your eligible prescription(s). Jump to more information about enrolling eligible prescriptions.
  • We will automatically refill and mail your qualified prescription before your refill due date, subject to your right to cancel any order.
  • We will contact your doctor to renew your prescription (that is, obtain a new prescription for the same medication) when it is either out of refills or about to expire.
  • We will alert you before your prescription is refilled at which time you may change or cancel the order.

You will always have an opportunity to change or cancel any automatic refill order before we begin processing it. You will have at least ten (10) days to change or cancel the order. If we do not provide you with at least ten (10) days to cancel, we will accept a return of the order and issue a full refund, including postage (if applicable). If you cancel all or part of an automatic refill order, the prescriptions you cancel will no longer be refilled automatically and will be unenrolled from the service.
 

If you do not cancel your automatic refill order, your prescription will be processed and shipped. Your current payment method will be charged for your co-pay when the order ships.
 

Copayment, co-pay or coinsurance is the amount a plan member is required to pay for a prescription in accordance with a plan. The amount may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with a balance, if any, paid by a plan.

We will notify you of an upcoming automatic refill order via your chosen communication method (either telephone, email or text). Please note that if you select automated phone calls or text messages, you may also receive notices by email or US postal mail.

 

You will have at least ten (10) days to change or cancel the order. If we do not provide you with at least ten (10) days to cancel, we will accept a return of the order and issue a full refund, including postage (if applicable). If you cancel all or part of an automatic refill order, the prescriptions you cancel will no longer be refilled automatically and will be unenrolled from the service.
 

To change or cancel an automatic refill order, call the number on your member ID card. You can also download, complete and mail a Cancellation Form (PDF) to us. If we do not receive the Cancellation Form before the date your order begins processing, which can be found on your order notification, we will not be able to process your cancellation request and your prescriptions will be automatically refilled and shipped.

When your prescription is about to expire or is out of refills, we will contact your prescriber for a new prescription for the same medication. If your prescriber does not respond or declines our request for a new prescription, we will contact you and ask you to follow-up with them to obtain a new prescription and mail it to us. If your prescriber responds to our request for a new prescription, we will process the prescription refill and send the medication to you.

No. If we receive a new prescription from your prescriber for your medication, you do not need to mail the new prescription to us. If you are not aware that your prescriber has replied to our request, the order processing system will see that the new prescription you mailed to us is a duplicate and it will be returned to you with a letter of explanation.

You will have at least ten (10) days to change or cancel your automatic refill order. Once the cancellation period has expired and you have not cancelled the order, we will begin processing your refill and it should ship within the next five (5) business days.

If you have a co-pay or coinsurance, we will charge the default payment option on file when your automatic refill order is shipped.

 

Copayment, co-pay or coinsurance is the amount a plan member is required to pay for a prescription in accordance with a plan. The amount may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with a balance, if any, paid by a plan.

If your prescription doesn’t arrive, contact us immediately. You can call the number on your member ID card or log in to your online account.

If you want to remove a prescription from the automatic refill program, log in to your online account or call the number on your member ID card and we’ll unenroll the prescription from the service for you.

You can log in to your online account and simply uncheck the box next to the prescription that you’d like to unenroll and then enroll the new prescription into the program by checking the box next to it. You can also call the number on your member ID card and we'll take care of the changes for you.

We will accept up to two (2) returned prescriptions filled through the automatic refill service that are either unwanted or unneeded, unless the prescription has been either partially or fully consumed. If we do not provide you with at least ten (10) days to cancel your automatic refill order, however, we will accept a return of the order and issue a full refund, including postage, if applicable, regardless of any history of returns.

For certain situations, the Centers for Medicare and Medicaid Services (CMS) requires that we get your consent before we can mail your automatic refill order to you. Your consent will be required if you are filling a prescription automatically under a new prescriptions benefits plan for the first time.

 

Costs and reimbursement

Your secure member website shows your personal pharmacy coverage and benefits information.
 

Log in to see your pharmacy coverage

Here are some tips to pay less out of pocket for your prescription drugs:
  • Ask your doctor to consider prescribing drugs that are on the Pharmacy Drug Guide (formulary).
  • Ask your doctor to consider prescribing generic drugs* instead of brand-name drugs.
  • Check to see if your plan includes our home delivery pharmacy service. Depending upon your plan, our home delivery service may save your money.
  • Remind your doctor to check your plan to make sure you get maximum coverage.  

Learn more about home delivery

If you have out-of-network benefits, and you use a pharmacy that is not in the Aetna network, you pay the full amount at the time of purchase. Then you can submit a claim and get reimbursed. You are still responsible for any copay or coinsurance. If you don't have out-of-network benefits, you will not be reimbursed.  

To submit a claim: 

  • Keep receipts for all prescriptions that you paid for out of your pocket. Your receipts must include your Aetna member ID number.
  • Print and complete the prescription drug claim form.
  • Mail the receipts and claim form to the address on the form within two years of the date of purchase.

Get the prescription drug form (English)
 

Get the prescription drug form (Spanish)

 

Drug coverage

To see if a drug is covered by your plan, log in to your secure member website. You can search by the drug name to see coverage information. 
 

Log in to see drug coverage information
 

If you prefer not to log in, and you know the name of your pharmacy plan and tier, you can view your formulary (drug list) online. Choose your plan type, then click on your tier level and select the "Commonly prescribed drug guide."
 

Find a formulary without logging in

All plans cover insulin. Coverage for other diabetic supplies varies by plan. See if your plan covers diabetic supplies by logging in to your secure member website. You also can email Member Services within your secure account to ask questions about your drug coverage. 

There are several reasons why a medication may not be covered:

  • It is experimental or new.
  • Your doctor prescribed it for a use that is not recognized by the U.S. Food and Drug Administration or other professional medical organizations.
  • It was given to you in a doctor's office (example: a measles vaccine). Mediations given in a doctor's office are not covered under your pharmacy benefits. Your medical plan may provide coverage.
  • What you thought was a medication is actually a medical device. For example, a glucose monitor is a device, not a medication. Your medical plan may provide coverage.  
  • There are over-the-counter medications that work the same way.
  • Your specific pharmacy plan may not include certain drugs. 
  • Research shows that the drug is not for safe for some people.

You can buy any drug your doctor prescribes, even if it is not covered by your plan. You will have to pay the full cost if the drug is not covered.


If you are denied coverage for a medication, talk to your doctor. He or she can advise you on the best steps to take.

Talk to your doctor about other possible drugs. You can also call Member Services at the number on your ID card. 

When you know you'll be away and may run out of your medication during your trip, you can request an extra supply before you go. Go to the Aetna participating pharmacy where you filled the original prescription. Your pharmacist may call Aetna for an exception that lets you get an early refill of your medication. 

Fully insured members can have their refills* scheduled to be filled at the same time.  This can help to avoid multiple trips to the pharmacy each month.  Just ask your pharmacist to call us to ask for an early full refill of your medication.  And schedule it to be filled at the same time your other prescriptions renew.  Keep in mind that the full month’s copayment will apply when you receive an early full refill.
 

*Certain restrictions may apply to medications that don’t treat long-term or recurring conditions. These can include antibiotics, controlled substances and pain medications. Prescriptions for these types of drugs generally need to be filled and dispensed as written by the doctor.

 

Formulary (drug list)

Our Pharmacy and Therapeutics Committee meets regularly to review new drugs, and new information about current drugs. We review them for their safety, effectiveness and current use in therapy.
 

This committee includes licensed pharmacists and doctors. They are currently in practice or are Aetna employees.
 

Once we complete our clinical review, we also consider overall value before adding or removing a drug from the formulary. We may recommend moving a drug to a different tier level. Or that it be placed on our Formulary Exclusions List and is no longer covered.  

The formulary can change because throughout the year:

  • New drugs are approved.
  • Existing drugs are removed from the market.
  • Prescription drugs may become available over the counter (without a prescription). Over-the-counter drugs are not generally covered in a formulary.
  • Brand-name drugs lose patent protection and generic versions become available. When this happens, the brand-name drug is likely to be covered at a higher cost, while generic versions may cost less. See the "Generic drugs" section on this page for more information. 

If you know the full name of your pharmacy plan and tier, you can view it online.


If you have a plan through your job - or your spouse's/partner's job - and don't know the name of your plan or tier, contact the Human Resources department of the employer that offers your coverage.  
 

Find your formulary
 

You also can log in to your secure member website to see if a specific drug is covered. 
 

Log in to see if a drug is covered

 

Generic drugs

Generic drugs contain the same active ingredients in the same amounts as the brand-name drugs and work the same way. They are proven to be just as safe and effective as brand-name drugs. So they have the same risks and benefits as brand-name drugs do. However, generic drugs typically cost less. When appropriate, your doctor may decide to prescribe a generic drug, or allow the pharmacist to substitute a generic drug. 
 

A generic drug is the same as a brand-name drug in: 

  • Dosage
  • Safety
  • Strength
  • Quality
  • The way it works
  • The way it is taken
  • The way it should be used

Compared with brand-name drugs, generic drugs may: 

  • Be a different color, shape or size
  • Have different fillers, binders, coloring agents and flavorings (these are called "inactive ingredients")

Most pharmacies can substitute a generic drug for a brand-name drug. In fact, many will make the switch automatically, unless your state law says they can't.
 

However, your doctor may have written "DAW" on your prescription. This stands for "dispense as written." It means that the pharmacy can't give you a generic drug without calling your doctor for approval. Doctors may write DAW if they believe the generic drug is not right for you. 

 

Home delivery

To start home delivery: 

Ask your doctor to write two prescriptions for your maintenance drug: 

  • A 30-day supply to fill at your local pharmacy
  • A 90-day supply with three refills. Fill out the order form and mail or fax it to us with your prescription and payment. The return address is on the form. The fax number is 1-877-270-3317.

Mail Service Order Form (English)

Mail Service Order Form (Spanish)

Read more about home delivery

 

Medical exceptions

In certain circumstances*, you or your prescriber can request a medical exception for a non-covered drug. To submit a request, call our Precertification Department at 1-855-582-2025, or fax a request to 1-855-330-1716. You also can mail a written request to CVS Health, ATTN: Aetna PA, 1300 E. Campbell Rd., Richardson, TX 75081. If the request is expedited a coverage determination will be made within 24 hours of receiving the request, and notify you or your prescriber of our decision. All medically necessary outpatient prescription drugs will be covered. If a medical exception is approved the member is responsible for the highest applicable copay after deductible depending upon the members pharmacy plan design.

*These circumstances exist when you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, or undergoing a current course of treatment using a non-covered drug.

 

Precertification

Precertification is one way that we can help you and your doctor find safe, appropriate drugs and keep costs down.
 

Precertification means that you or your doctor need to get approval from the plan before certain drugs will be covered. 

Generally, precertification 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

An 8-year-old member needs an antibiotic called tetracycline. This drug should be carefully prescribed for children ages 8 and under. There is a risk it can change the color of their teeth. 
 

As a result, precertification is required. It makes sure the child has a medical need for the drug. If so, the drug will be approved for coverage.

  • You or your doctor can call the Aetna Pharmacy Precertification Unit at 1-800-414-2386
  • You can log in to your secure member website and submit a request through the Contact Us feature. 
  • You or your doctor can fill out a request form and send it to us:
    • By fax. The fax number is on the form. 
    • Through our provider portal on Availity - only your doctor can use this option. 
    • By mail. The mailing address is:

    Aetna Pharmacy Management
    1300 East Campbell Road
    Richardson, TX 75081 

Get a precertification request form

 

Quantity limits

Quantity limits help your doctor and pharmacist make sure that you use your drug correctly and safely.
 

We use medical guidelines and FDA-approved recommendation from drug makers to set these coverage limits. The quantity limit program includes:

  • Dose efficiency edits - Limits prescription coverage to one dose per day for drugs that have approval for once-daily dosing. 
  • Maximum daily dose - If a prescription is less than the minimum or higher than the maximum allowed dose, a message is sent to the pharmacy. 
  • Quantity limits over time - Limits prescription coverage to a specidic number of units over a specific amount of time. 
  • A member needs Imitrex.
  • Two prescriptions are written: The first is for nine tablets of Imitrex 50mg. The other is for nine tablets of Imitrex 100mg. This totals 18 tablets per month using both strengths. But the quantity limit for the drug is nine tablets per month. 
  • The member has a medical need for the two strengths and amounts requested.
  • The prescribing doctor must contact Aetna to ask for an exception to the quantity limit.

To request an exception: 

  • You or your doctor can call the Aetna Pharmacy Precertification Unit at 1-800-414-2386.
  • You can log in to your secure member website and submit a request throu the Contact Us feature.
  • You or your doctor can fill out a request form and send it to us: 
    • By fax. The fax number is on the form. 
    • Through our secure provider website, Navinet - only your doctor can use this option. 
    • By mail. The mailing address is: 
  • Aetna Pharmacy Management 
    1300 East Campbell Road
    Richardson, TX 75081
     

Get a quantity limits exception form

 

Specialty pharmacy

To order prescription medications through the network specialty pharmacy:

Get a patient profile form
 

Read more about our specialty pharmacy

 

Step therapy

Some drugs require step therapy. This means that you must try one or more other drugs before a step therapy drug is covered.
 

The other drugs are called prerequisite drugs. They are equally effective, have FDA approval and may cost less. They treat the same condition as the step therapy drug. 
 

If you don't try the other drugs first, you may need to pay full cost for the step therapy drug. 

To request an exception:

  • You or your doctor can call the Aetna Pharmacy Precertification Unit at 1-800-414-2386
  • You can log in to your secure member website and submit a request through the Contact Us feature. 
  • You or your doctor can fill out a request form and send it to us: 
    • By fax. The fax number is on the form. 
    • Through our secure provider website, Navinet - only your doctor can use this option. 
    • By mail. The mailing address is:
  • Aetna Pharmacy Management
    1300 East Campbell Road
    Richardson, TX 75081 
     

Get a step-therapy request form

Legal notices

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna).

This material is for information only. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Information is believed to be accurate as of the production date; however, it is subject to change.