Your pharmacy benefits and insurance plan may use words and phrases you don’t hear every day. We want to make sure you understand these terms. That way, when you get a prescription filled, you’ll feel more confident about knowing what is covered, and what you pay.
Here, you’ll find:
Sometimes you need to know the meaning of terms used in your medical plan, too. No problem. Just look them up in our glossary.
Annual notice of change
A letter, sent to members in some plans, explaining changes to their prescription drug plan. The letter is sent at the end of every year. And it affects drugs during the next plan year. The letter may be sent by e-mail or mail.
The services, drugs and products covered by your health insurance or benefits plan. This word is also used to describe your health plan in general.
A drug sold under a speciﬁc name by a drug-maker. In most cases, these drugs are protected by a patent. This means the drug-maker is the only manufacturer of this medicine.
A condition that lasts or keeps coming back over a long period of time. It may be treated with maintenance medicines.
With a closed formulary, your plan covers many drugs — but it does not cover drugs on the Formulary Exclusions List. This is a list of drugs your plan does not cover because there are less expensive alternatives available that are just-as-effective. When you have a plan with a closed formulary, you can view the complete Formulary Exclusions List on our website.
What you pay for covered prescription drugs after you pay your deductible. Your health plan pays the rest. It is usually a percentage. For example, you pay 10 percent and your health plan pay 90 percent.
Complex chronic condition
A long-term condition that may require you to take specialty medicine. Examples of these conditions are rheumatoid arthritis and multiple sclerosis.
The dollar amount you pay for prescription drugs. For example, you may pay $25 for brand-name drugs. In most plans, you pay this after you meet your deductible.
The amount you pay for covered prescriptions before your health plan begins to pay. For example, your plan might have a $1,500 deductible. After you pay that amount, you may pay a lower copay or coinsurance.
A family member who is covered by your plan. This person can be a child, spouse or domestic partner.
A natural, live or man-made ingredient used to treat an illness. “Medicine” is another common word for “drug.”
Tiers are coverage levels for drugs. This level determines how much you might pay out of pocket for a drug. You may see tiers grouped by generic, brand-name, preferred or non-preferred drugs.
A drug, product or service that is not covered by your plan.
Flexible Spending Account (FSA)
An account that lets you set aside money to pay for your health care or prescriptions. It also may help you save on taxes. Money is taken from your paycheck and placed in an account. You use the account to pay for health care costs throughout the plan year. You must use the money by the end of the plan year or it will be lost. And you can’t take it with you if you leave your job.
A list of generic and brand-name drugs that your prescription plan mostly covers. But it is not a guarantee of coverage. It is also known as the “Pharmacy Plan Drug List.” You may pay less for drugs on this list. You and your doctor should decide together what drug(s) are right for you.
A “copy” of a brand-name drug. It has the same basic ingredients as the brand drug. Plus, the U.S. Food and Drug Administration has found that it is just as safe and effective as the brand drug. Generic drugs usually cost less than brand drugs. So you may save money by choosing generics.
Health Reimbursement Arrangement (HRA)
Part of a health plan that gives you a fund to pay for some health care costs. Your employer puts money into the fund. You use the fund to pay out-of-pocket costs, like copays, or deductibles. Unused money is rolled over and can be used in the next plan year. But you can’t take the fund with you to a new job or health plan.
Health Savings Account (HSA)
Part of a health plan that helps you pay for prescriptions and other health care costs. You and your employer can put money into this account. You use that money to pay for qualified health care costs. Or you can save the account to use in the future. The account grows interest over time. You pay no taxes on money you put into the account. And you pay no taxes on money you use for qualified costs.
The card you get when you join a health plan. It shows you have a health plan.
You and your family will receive Aetna ID cards in the mail. Look for an “Rx” on your card. This shows the pharmacist that you are an Aetna member with prescription drug benefits. The card also includes a phone number to call Rx Member Services. Always take your ID card with you to the pharmacy.
You can print a temporary card through your Aetna Navigator® member website. Go to www.aetna.com, register and sign in. Click “Get an ID Card.” If your card is lost or stolen, call 1-800-872-3862 to report it.
Restrictions that tell you what your health plan does and doesn’t cover. They are chosen by the plan sponsor. They also tell you what must be done before something is covered.
A pharmacy that sends you your medicine through the mail. It fills prescriptions for maintenance medicine. This type of medicine is used regularly, to treat conditions like asthma, diabetes or arthritis.
If you need a maintenance medicine, you can get up to a 90-day supply, or the maximum allowed by your plan. Check your plan documents to see if your plan includes our mail-order pharmacy.
Prescription drugs that are taken on a regular basis. These drugs help treat chronic conditions such as high blood pressure.
Medicare Part D
A Medicare prescription drug beneﬁt.
The time period when you can make choices about your health plan coverage for the next year.
An open formulary means your plan covers most prescription drugs. But it may not cover some others.
The part of the costs you pay for your health care. Copays, coinsurances and deductibles are examples.
A limit on the costs you pay for covered services after you meet your deductible. Your plan pays 100 percent of the costs of covered services after you reach this amount. The limit usually is yearly.
Drugs that can be bought without a prescription. They are not covered under most prescription plans. Aspirin, Prilosec OTC and cold remedies are examples.
A pharmacy that has a contract with your health plan. Use a participating pharmacy to ﬁll your prescriptions and get the most from your plan. You can only use your prescription benefits at a pharmacy that contract with your plan.
A group of pharmacies that has a contract with your health plan. Pharmacies in our network give us lower rates. That means lower drug prices — and lower costs for you.
A drug coverage review that might be part of your plan.* This review requires you to get approval for some drugs or services before you plan covers them. This is for drugs or services that:
Here’s an example:
The antibiotic tetracycline can discolor children’s teeth. So we review requests for this medicine to make sure the child has a medical need for it. If so, we will cover it.
Instructions from a doctor or other health care provider about the care of a patient. It may include direction for the patient, caregiver, nurse, pharmacist or other therapist.
A drug regulated by the government that requires a prescription to be bought. The term is used to separate it from over-the-counter drugs. These don’t require a prescription.
A community pharmacy where you can get your prescription drugs.
A symbol that means “prescription” or “pharmacy.”
A drug coverage review that might be part of your plan.* It helps make sure members get a safe amount of their drug. This is for drugs that:
Here’s an example:
The recommended limit for Imitrex® is nine tablets a month. But a member gets two prescriptions: one for nine tablets of Imitrex 50 mg, the other for nine tablets of Imitrex 100 mg. This amount is greater than the recommend dose. A doctor can ask for an exception if there is a medical need for this dose.
Drugs taken for complex chronic conditions such as rheumatoid arthritis or HIV. These drugs are injected, given by an IV or taken by mouth. These drugs can cost more and require more monitoring than other types of drugs. And they may not be available at retail pharmacies.
A type of pharmacy that fills prescriptions for specialty medicine. These types of drugs may be injected, given by an IV or taken by mouth. Specialty medicine often needs special storage and handling. It must be delivered quickly. And a nurse or pharmacist should oversee your treatment.
Aetna Specialty Pharmacy® is our specialty pharmacy. It fills prescriptions for specialty medicine through the mail. It also offers extra support throughout your treatment.
A drug coverage review that might be part of your plan.* It means your doctor may need to prescribe certain drugs first, before another drug will be covered. The drugs prescribed first work the same and treat the same condition. But they may cost less.
Here’s an example:
Boniva® is a drug that requires step therapy. When we get a Boniva prescription, we call the doctor to confirm medical need. If clinical standards are met, the prescription is filled. If not, the doctor needs to prescribe another drug that meets step-therapy requirements.
This happens when two drugs of the same type are prescribed at the same time. Rarely is this needed to treat a medical condition. Taking these drugs at the same time may be harmful to your health.
You might also see some terms used here at Aetna. If you come across one you don’t understand, just look it up. When you do, you can better use your benefits.
Aetna Formulary Exclusions List
A list of drugs that are only covered if you have a medical exception.
Aetna Pharmacy Plan Guide
A yearly booklet that lists preferred and non-preferred drugs. These drugs may or may not be covered by a plan. The guide does not include every drug on the market. Instead, it lists the most commonly prescribed drugs available for coverage. They represent drug classes in which we have manufacturer agreements.
Aetna Pharmacy Management
The Aetna group that manages prescription beneﬁts and insurance plans.
Aetna Pharmacy Plan Drug list (formulary)
A list of medicines preferred by Aetna prescription plans. It is also known as a “formulary.” The Pharmacy Plan Drug list is not a complete list of covered drugs. Some plans may not cover certain drugs on this list.
Aetna Rx Home Delivery®
Our mail-order pharmacy service. It fills your prescriptions for maintenance medicine. This type of medicine is used regularly to treat conditions like arthritis, asthma or diabetes.
If you need this type of drug, you can get up to a 90-day supply or the maximum supply allowed by your plan, and:
Check your plan documents to see if you have our mail-order pharmacy.
Aetna Specialty Pharmacy
This is our specialty pharmacy. It can fill your prescription for specialty medicine. These types of drugs may be injected, given by IV or taken by mouth.
Specialty medicine often needs special storage and handling. It must be delivered quickly. And a nurse or pharmacist should oversee your treatment. Use Aetna Specialty Pharmacy to get:
Aetna's Pharmacy Plan Drug Lists are subject to change.
Aetna Specialty Pharmacy and the Specialty Pharmacy Network may not be available to California HMO members. Talk to your doctor about the appropriate way to get the specialty medications you need. Doctors may have agreed to dispense and administer these drugs to you themselves. Or they may write a prescription so you can fill them at any participating retail or mail-service pharmacy.