Pharmacy Clinical Criteria - Pharmacy Clinical Policy Bulletins

Guides for prescription drug coverage

These guides help us make coverage decisions for members whose plans cover outpatient prescription drugs. They explain what drugs will be covered.

Pharmacy clinical policy bulletins and pharmacy clinical coverage criteria are highly technical. They are meant to be used by health care professionals.

These bulletins and criteria usually are for drugs that are on the Preferred Drug List, or require precertification or step therapy.

Aetna Commercial Prescription Drug Plans

2015 Coverage Criteria

Aetna Individual Formulary Precertification
Aetna Individual Formulary Step Therapy
Aetna Small Group Essential Formulary Precertification
Aetna Small Group Essential Formulary Step Therapy
Aetna Premier and Premier Plus Formulary Precertification and Step Therapy
Aetna Value and Value Plus Formulary Precertification 
Aetna Value and Value Plus Formulary Step Therapy
Aetna Commercial Formulary for Fully Insured Plans
Aetna Commercial Formulary for Self-Insured Plans

Pharmacy Prescription Drug Prior Authorization Request Forms

Standard request form
California residents only
Colorado residents only

2014 Coverage Criteria

Search our 2014 Pharmacy Clinical Policy Bulletins (PCPBs) for Commercial Formulary Plans

 
 
 

2014 Health insurance exchange prescription drug plans

Find information about prescription drug plans offered on public exchanges.

Individual prior authorization criteria
Individual step-therapy criteria
Small group prior authorization criteria
Small group step-therapy criteria

2014 Aetna Commercial (non-Medicare) Prescription Drug Plans Formulary-2

Find information about drugs on this formulary.

2014 Aetna Commercial Formulary-2 prior authorization criteria
2014 Aetna Commercial Formulary-2 step-therapy criteria

 

Aetna Medicare prescription drug plans

We also provide information about our Medicare prescription drug plans.

See our Medicare information

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Clinical Policy Bulletins

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  • Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits and do not constitute dental advice. Treating providers are solely responsible for dental advice and treatment of members. Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to their coverage or condition with their treating provider.
  • While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's current determinations of whether certain services or supplies are medically necessary, based upon a review of available clinical information. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. Aetna's conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna). Your benefits plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a State or the Federal government.
  • Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change.
  • Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and are designed to be used by our professional staff in making clinical determinations in connection with coverage decisions, members should review these Bulletins with their providers so they may fully understand our policies.
  • Under certain plans, if more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that certain terms are met.
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