Frequently asked questions about pharmacy coverage
Choose a category below to see questions and answers about pharmacy coverage.
Drug coverage
Is my medication covered?
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
Are diabetic supplies covered under my prescription plan?
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.
Why isn't my medication covered?
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.
How do I find out if I can take another drug in place of one that's not covered?
Talk to your doctor about other possible drugs. You can also call Member Services at the number on your ID card.
I'll be out of town for a while. How can I get an extra supply of my prescription medication?
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.
I take multiple prescriptions. Can I arrange to have them filled all at the same time each month?
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)
How is the formulary developed?
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.
Why can the formulary change during the year?
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.
Where can I see my pharmacy plan's formulary?
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.
You also can log in to your secure member website to see if a specific drug is covered.
Costs and reimbursement
How much will my drugs cost?
Your secure member website shows your personal pharmacy coverage and benefits information.
Log in to see your pharmacy coverage
How can I save on prescriptions?
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
Can I get reimbursed for prescription medications I bought from a pharmacy that is not in Aetna's network?
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.
Generic drugs
What are 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")
What can I do at the pharmacy to get the generic version of a drug?
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.
Precertification
What is 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
What is an example of precertification?
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.
The drug my doctor prescribed requires precertification. How can I request precertification (or an exception to precertification)?
If you need a drug that requires precertification:
- 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
Step therapy
What is 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.
The drug my doctor prescribed requires step therapy. If the drug is necessary for treating my condition, how can I get an exception?
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
Quantity limits
What are 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.
What is an example of quantity limits?
- 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.
The drug my doctor prescribed requires quantity limits. If they prescribe a higher drug quantity because it is medically necessary for treating my condition, can I get 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
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.
Specialty Pharmacy
To order prescription medications through the network specialty pharmacy:
- Your doctor can fax your prescription to 1-866-FAX-ASRX (1-866-329-2779).
- Your doctor can speak to one of our registered pharmacists at 1-866-782-2779, Mon-Fri, 8 a.m. - 7 p.m. ET. (TDD:1-866-833-2779)
- Your or your doctor can mail your prescription to us. Please mail it with a completed patient profile form. The mailing address is on the form.
After we receive your prescription, your first order should ship within 48 hours. It may take longer if we need to contact your doctor about the prescription.
Medical Exception
Medical Necessity 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.