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Pharmacy coverage FAQs

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Automatic refill program

When you enroll qualified prescriptions into the program, we’ll automatically refill and ship your prescriptions to you at the right time. We’ll also contact your doctor to renew an enrolled prescription before the last refill or if it’s about to expire.

 

You choose which prescriptions to have filled automatically. However, not all prescriptions are eligible for the program. To learn more, check “Are all of my prescriptions eligible?” below.

 

When you enroll a prescription, you need to choose how to get updates about upcoming automatic refill orders. This can be an automated phone call, email or text message. If you choose phone calls or texts, you may also receive updates by email or U.S. postal mail.

There’s no cost for the automatic refill program. Your refills will be mailed to before you run out of medication — with no service, shipping or handling charges. You’ll only be charged a copay or coinsurance when your order ships.

 

If you request expedited shipping, there may be a charge.

 

You may need to pay a copay or coinsurance for a prescription under your plan. This amount may be a deductible, a percentage of the prescription price, a fixed amount or other charge. The balance, if any, is paid by your 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 can help you stay healthier and avoid costly emergency room visits and hospital stays.

Log in or register for your member website to choose the eligible prescriptions you want to enroll. Or we can enroll your prescriptions in the program for you. To get started, call the number on your member ID card.

The service is available for many common medications taken for long-term therapy. These are called maintenance medications. This includes drugs to help manage high blood pressure, high cholesterol and diabetes.

 

Not all prescriptions are eligible for automatic refills. Medications such as controlled substances, specialty drugs and prescriptions covered by certain government payers, including Medicare Part B, aren’t eligible.

 

To learn which of your prescriptions qualify for automatic refills, log in to your member website. Or call the number on your member ID card.

When you enroll a prescription in the program, you choose how to get updates about upcoming automatic refill orders. You can get an automated phone call, email or text message. If you choose phone calls or texts, you may receive updates by email or U.S. postal mail.

Here's how the service works:

 

  • Enroll your eligible prescription(s). For more information, review “Are all of my prescriptions eligible?” above.
  • We’ll automatically refill and mail your prescription before your refill due date unless you cancel the order.
  • If your prescription is out of refills or about to expire, we’ll contact your doctor to get a new prescription for the same medication.
  • We’ll alert you before your prescription is refilled. At that time, you can change or cancel the order.

We’ll let you know about an upcoming order through the contact option you chose — phone, email or text message. If you chose phone calls or texts, you may also get updates by email or U.S. postal mail.

 

You have at least ten days to change or cancel your order. Be sure to let us know before the date your order begins to process. You can find this date on your order notice. If we don’t give you at least ten days to cancel your order, we’ll return the order and issue a full refund, including postage, if any. If you cancel all or part of an automatic refill order, we’ll remove those prescriptions from the program.

 

You have two ways to change or cancel an order:

 

  1. Call the number on your member ID card, or
  2. Complete a cancellation form and mail it to us. You can find this form on your member website.

When your prescription is about to expire or is out of refills, we’ll contact your prescriber to get a new prescription for the same medication.

 

  • If your prescriber responds to our request: We’ll process the prescription refill and send your medication to you.
  • If your prescriber doesn’t respond or declines our request: We’ll ask you to follow up with them to get a new prescription and mail it to us.

No. If we receive a new prescription for your medication from your prescriber, you don’t need to mail the new prescription to us.

 

Not sure if your prescriber has replied to our request? Rest assured, we’ll know that the new prescription you mailed to us is a duplicate, and we’ll return it to you.

You have at least ten days to change or cancel your automatic refill order. If you haven’t cancelled your order during that time, we’ll refill your medication. It should ship within the next five business days.

If you have a copay or coinsurance with your plan, we’ll charge your default payment option when we ship your automatic refill order.

 

A copay or coinsurance amount may be a deductible, a percentage of the prescription price, a fixed amount or other charge. The balance, if any, is paid by your plan.

If your prescription is lost or delayed, contact us right away. You can call the number on your member ID card or log in to your member website.

To remove a prescription from the automatic refill program, log in to your member website. Or call the number on your member ID card and we’ll remove the prescription for you.

Here’s how to remove a prescription and replace it with a new one:

 

  • Log in to your member website.
  • Uncheck the box for the prescription you want to remove.
  • Check the box for the new prescription you want to add.

Need help? Call the number on your member ID card and we'll take care of the change for you.

If you don’t want or need a prescription, no worries. You can return up to two prescriptions filled through the automatic refill program. To get a refund, just be sure the prescription isn’t partially or fully consumed.

 

If you don’t get at least ten days to cancel your automatic refill order, you can return the order for a full refund, including postage, regardless of return history.

Sometimes, the Centers for Medicaid and Medicaid Services (CMS) requires that we get your consent before we can mail an automatic refill order to you. For instance, if you’re auto filling a prescription under a new prescription benefits plan for the first time, your consent is required.

 

Costs and reimbursement

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

 

Log in to check 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.
  • Remind your doctor to check your plan to make sure you get maximum coverage.
  • Check if your plan includes our home delivery services. This may help you save.

Learn more about home delivery

If you have out-of-network benefits, you pay the full amount of the prescription at the time of purchase. You can submit a claim to get your money back. Keep in mind that you’re still responsible for any copay or coinsurance. If you don’t have out-of-network benefits, you won’t be reimbursed.

 

To submit a claim:

 

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

Prescription drug claim form - English (PDF)
 

Prescription drug claim form - Spanish (PDF)

 

Drug coverage

To find out if a drug is covered by your plan, use your member website. You can search by drug name to check coverage information.

 

Log in to find drug coverage

 

Want to search without logging in? If you know the name of your pharmacy plan, you can check your formulary (drug list) online. Once you choose your plan year and plan type, we’ll take you to our “Find a covered drug“ tool. You can also review the Aetna drug guide in PDF format.

 

Find drug coverage without logging in

All plans cover insulin. Coverage for other supplies to manage diabetes varies by plan. To find out what your plan covers, log in to your member website. Once you’re logged in, you can also email Member Services to ask questions about your coverage.

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

 

  • It's experimental or new.
  • Your doctor prescribed it for a use that is not recognized by the U.S. Food and Drug Administration (FDA) or other professional medical organizations.
  • It was given to you in a doctor's office (example: a measles vaccine). Your pharmacy benefits do not cover medications given in a doctor’s office. Your medical plan may provide coverage.
  • What you thought was a medication is 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 safe for some people.

You can buy any medication your doctor prescribes, even if it isn’t covered by your plan. You’ll just need to pay the full cost.

 

If you’re denied coverage for medication, talk with your doctor. They can advise you on the best steps to take.

Talk with your doctor about other medications that may be right for you. 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 us for an exception to get an early refill of your medication.

Yes. Fully insured members can get refills* scheduled at the same time. This can help avoid many trips to the pharmacy each month.

 

To get started, ask your pharmacist to call us to request 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 a full month’s copay applies for early full refills.

 

Notes

 

*FOR REFILL DETAILS: Some medications that don’t treat long-term or recurring conditions need to be filled and dispensed as written by the doctor. This can include antibiotics, controlled substances and pain medications.

 

Formulary (drug list)

We design our formularies to meet the expectations of members, health care professionals and customers for quality, cost-effective pharmacy benefits. Our formularies include FDA-approved brand and generic drugs, including specialty drugs.

 

Every quarter, we review each formulary in depth. We also review therapeutic classes:
 

  • When a new product is added to a class of drugs
  • When there is new clinical information about the therapeutic class
  • As necessary

As brands lose their patent and generics become available, you may pay more. Or we may remove it from the formulary.

 

We base formulary decisions on an extensive review of FDA-approved drugs. We maintain a Pharmacy and Therapeutics (P&T) Committee to provide clinical input on all decisions. We may invite others outside or within our company who have specialized or unique knowledge, skills, and judgment to participate in the review process.

The formulary can change throughout the year because:

 

  • 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. Review the "Generic drugs" section on this page for more information.

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

 

Not sure of the plan name or tier? If you have a plan through your job — or your spouse’s or partner’s job — contact that employer’s HR department.

 

Find drug coverage without logging in

 

You can also use your member website to learn if a specific drug is covered.

 

Log in to find drug coverage

You’re covered for all types of medicine — some more expensive, and some less. Here are tier definitions for the following plans:
 

  • Advanced Control - Aetna
  • Advanced Control - Aetna California
  • Advanced Control - Aetna Student Health

    • Preferred generic: the lowest cost
    • Preferred brand: a slightly higher cost
    • Non-preferred brand and generic: a higher cost
    • Preferred Specialty: lower cost for specialty drugs
    • Non-preferred Specialty: higher cost for non-preferred specialty drugs

Your pharmacy plan may not have all of these coverage levels. Check your plan documents to see how much you’ll pay.
 

  • Advanced Control
  • Advanced Control Choice
  • Aetna Standard Plan
  • Aetna Standard Plan- DOD
  • Basic Control
  • Basic Control with ACSF
  • High Value Plan
  • Standard Control Plan
  • Standard Control Choice Plan
  • Standard Control Choice with ACSF
  • Standard Opt Out - Aetna
  • Standard Opt Out- Aetna Student Health
  • Standard Opt Out Plan
  • Standard Opt Out Plan with ACSF

    • Generic: the lowest cost
    • Preferred brand: a slightly higher cost
    • Non-preferred brand: a higher cost
    • Preferred Specialty: lower cost for specialty drugs
    • Non-preferred Specialty: higher cost for non-preferred specialty drugs

Your pharmacy plan may not have all of these coverage levels. Check your plan documents to see how much you’ll pay.

 

Generic drugs

Generic drugs contain the same active ingredients in the same amounts as 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 pharmacies 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 (PDF)

 

Mail service order form - Spanish (PDF)

 

Learn more about home delivery

 

Medical exceptions

In certain cases, you or your prescriber can request a medical exception to the precertification, step therapy or quantity limits requirements, or for a drug that’s not covered on your plan. You can ask for your request to be expedited and you or your prescriber will receive a decision within 24 hours. All medically necessary outpatient prescription drugs will be covered. If a medical exception is approved, you only need to pay the copay after the deductible. This amount is based on your pharmacy plan.


Your provider can:
 

  • Submit the request through our secure Availity provider website.
  • Call the Aetna Pharmacy Precertification Unit: NonSpecialty 1-800-294-5979 ${tty} or Specialty 1-866-814-5506 ${tty}.
  • Fax the completed request form to: Non-Specialty 1-888-836-0730 or Specialty 1-866-249-6155.
  • Mail the completed request form to:

    Medical exception to pharmacy prior authorization
    Unit 1300 East Campbell Road
    Richardson, TX 75081.
 

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 eight-year-old member needs an antibiotic called tetracycline. This drug should be carefully prescribed for children ages eight 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 ${tty}.
  • You can log in to your 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 Availity® provider portal. (Only your doctor can use this option.)
    • By mail. The mailing address is:

    Aetna Pharmacy Management
    1300 East Campbell Road
    Richardson, TX 75081

Precertification request form (PDF)

 

Quantity limits

Quantity limits help your doctor and pharmacist make sure that you use your medicine 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 specific 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.

Yes. To request an exception:

 

  • You or your doctor can call the Aetna Pharmacy Precertification Unit at 1-800-414-2386 ${tty}.
  • You can log in to your 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
     

Quantity limits exception form (PDF)

 

Specialty pharmacy

To order prescription medications through the network specialty pharmacy:

 

Specialty pharmacy enrollment form (PDF)
 

Learn more about our specialty pharmacy

 

Step therapy

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


These first-line drugs are called prerequisite drugs.

 

  • They are equally effective.
  • They have approval from the U.S. Food and Drug Administration (FDA).
  • They treat the same condition as the step therapy drug.
  • They may cost less.

If you don't try the appropriate first-line drug, 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 ${tty}
  • You can log in to your 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 
     

Step therapy request form (PDF)

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).

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.

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