2018 Drug Coverage
Changes to this guide effective 1/1/18
Changes to this guide effective 4/1/18
Changes to this guide effective 7/1/18
There are no changes to this guide for 10/1/18
2018 - Clinical Policy Bulletins
Medical exceptions for non-covered drugs
Expedited 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 Aetna PA, 1300 E. Campbell Rd., Richardson, TX 75081. We will make a coverage determination within 24 hours of receiving the request, and notify you or your prescriber of our decision.
*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.
*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.
About your drug list
What is a formulary?
A formulary is a list of drugs covered under your plan, with details about the type of coverage. You may hear the word "formulary" during a doctor’s visit or when you pick up a prescription.
What do tiers have to do with how much I pay?
A tier is a level of coverage. If you have a two-tier plan, you have two levels of coverage. A five-tier plan has five levels. Tier 1 drugs are generic drugs, and you pay less for these. You have a higher copay for drugs that are in higher tiers.
What do “open” and “closed” mean?
A closed drug list (also called a closed formulary) covers only the drugs on the list. If a drug doesn’t appear on the list, it is not covered.
An open drug list (also called an open formulary) gives some coverage to drugs that are not listed, but you will generally pay more.
Does the main list include every covered drug?
Your pharmacy benefits plan includes thousands of drugs – too many to list. So your main drug list contains only the most commonly prescribed drugs.
For current Aetna members, to check coverage and copay information for a specific medicine log in to your secure member website.
This material is for information only. Aetna Specialty Pharmacy refers to Aetna Specialty Pharmacy, LLC, a subsidiary of Aetna Inc., which is a licensed pharmacy that operates through specialty pharmacy prescription fulfillment. The drugs on the Preferred Drug List Formulary Exclusions, Precertification, Quantity Limit and Step-Therapy Lists are subject to change. The precertification, quantity limits and step-therapy drug coverage review programs are not available in all service areas. For example, precertification and step therapy programs do not apply to fully insured members in Indiana. Step therapy does not apply to fully insured members in New Jersey. However, these programs are available to self-insured plans.
Information is believed to be accurate as of the production date; however, it is subject to change.
