Getting
To Know
Your Aetna
Prescription
Drug Plan
As with any
prescription drug
plan, it’s important
to learn which
drugs are covered
and which coverage
requirements apply.
Covered Medications
Our Preferred Drug List — also called a
“formulary” — offers you and your doctor a
choice of quality, cost-effective, FDA-approved
generic and brand-name medications. These
drugs were selected with input from a variety
of health care specialists.
Your prescription drug benefits are based
on an “open formulary.” This means that
your plan covers brand-name and generic
medications on Aetna’s Preferred Drug List,
as well as many others that are not listed.
It is also possible that you will have a lower
copayment for drugs on the Preferred Drug
List. You can view our most up-to-date
Preferred Drug List and learn about
medication alternatives by visiting
www.aetna.com/formulary. If you
are already an Aetna member, you can
view your plan-specific information on
the Aetna Navigator™ secure member
website at www.aetna.com.
Precertification and
Step-Therapy*
Based on FDA guidelines and current
medical findings, Precertification and
Step-Therapy support member safety and
appropriate drug use, and they help keep
health care costs manageable by requiring
certain conditions for coverage. Drugs that
require Precertification or Step-Therapy
can be found on our website at
www.aetna.com/formulary.
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Precertification
Precertification helps encourage safe,
cost-effective use of prescription drugs
by requiring “prior authorization” from
Aetna before the drug will be covered.
For example, certain antibiotics, such
as tetracycline, should be carefully
prescribed to children age eight
and under. Tetracycline can cause
discoloration of children‘s teeth.
Step-Therapy
Employers continue to be challenged by
rising drug costs as they strive to provide
quality, affordable drug benefits to their
employees. Another way Aetna tries to
encourage appropriate, cost-effective
drug use is through a program called
Step-Therapy.
With Step-Therapy, some drugs are
covered by your benefits plan only after
one or more “prerequisites,” clinically
appropriate and cost-effective alternative
drugs, are tried first — unless your doctor
obtains a medical exception. These
alternative medications, found on Aetna’s
Step-Therapy List, are used to treat the
same conditions as the drugs requiring
Step-Therapy.
*If included in your plan. Precertification and
Step-Therapy programs do not apply to members
in Indiana. Step-Therapy is not available in
New Jersey. In Texas, precertification approval
is known as preservice utilization review and is
not “verification” as defined by Texas law.
Requesting Precertification
and Medical Exceptions
If your medication requires Precertification,
your doctor may contact Aetna by phone,
fax, or e-mail. In addition, he or she may
submit a medical exception request for
coverage if you must use a drug on our
Step-Therapy List. If your doctor’s request
is not approved, you can still get the drug.
But you will have to pay the full price of
the prescription.
Over-the-Counter Drugs
Many medical conditions can be treated
safely with drugs available over the counter.
These medications have been approved by
the FDA as safe and effective, and they
often have the same active ingredients as an
original prescription version. Always consult
with your doctor before taking over-thecounter medications.
Your plan does not cover medications that
have over-the-counter equivalents, including
such remedies as Claritin® and Prilosec®
20 mg. Please ask your doctor if an over-thecounter medication is appropriate for you.
It may help you save money!
Limitations and
Exclusions
Drugs that are not covered under
the standard prescription drug
benefit program include but are
not limited to: drugs used for the
purpose of weight reduction (i.e.,
appetite suppressants), including the
treatment of obesity ■ over-the-counter
medications ■ nutritional supplements ■
smoking cessation aids or drugs ■
growth hormones ■ prophylactic drugs
for travel ■ test agents and devices,
excluding diabetic test agents ■
performance, athletic performance,
or lifestyle enhancement drugs and
supplies ■ cosmetics or any drugs
used for cosmetic purposes or to
promote hair growth, including health
and beauty aids ■ replacement for
lost or stolen prescriptions.
For a complete listing of medications
not covered by your prescription drug
benefits program, refer to your plan
documents after enrollment.
Find Out More
Claritin® is a registered trademark of Schering-Plough HealthCare Products Inc.
Prilosec® is a registered trademark of AstraZeneca LLP.
“Aetna” is the brand name used for products and services provided by one or more of the Aetna group of
subsidiary companies. The Aetna companies that offer, underwrite or administer benefits coverage include:
Aetna Health Inc., Aetna Health of California Inc., Aetna Health of the Carolinas Inc., Aetna Health of Illinois
Inc., Aetna Health Insurance Company of New York, Corporate Health Insurance Company and/or Aetna Life
Insurance Company. Aetna Pharmacy Management refers to an internal business unit of Aetna Health
Management, LLC.
If your plan covers outpatient prescription drugs, your plan may include a drug formulary (Preferred Drug List). The Preferred Drug
List includes prescription drugs generally covered under your prescription drug benefits plan on a preferred basis subject to applicable
limitations and conditions. Your pharmacy benefit is generally not limited to the drugs listed on the formulary. The medications listed
on the formulary are subject to change in accordance with applicable state law. For information regarding how medications are
reviewed and selected for the formulary, formulary information, and information about other pharmacy programs such as
Precertification and Step-Therapy, please refer to Aetna’s website at www.aetna.com, or the Aetna Medication Formulary Guide.
Many drugs, including many of those listed on the formulary, are subject to rebate arrangements between Aetna and the
manufacturer of the drugs.
Rebates received by Aetna from drug manufacturers are not reflected in the cost paid by a member for a prescription drug. In
addition, in circumstances where your prescription plan utilizes copayments or coinsurance calculated on a percentage basis or a
deductible, use of formulary drugs may not necessarily result in lower costs for the member. Members should consult with their
treating physicians regarding questions about specific medications. Refer to your plan documents or contact Member Services for
information regarding the terms and limitations of coverage.
Some medications, such as oral contraceptives, erectile dysfunction medications, diabetic supplies and infertility medications, may
only be covered if additional, optional coverage has been added to your standard prescription drug benefit plan.
Please refer to your plan documents for further information.
Precertification and Step-Therapy requirements are based on current medical findings, FDA-approved, drug labeling information, and
cost and manufacturer rebate arrangements. This material is for informational purposes only and is neither an offer of coverage nor
medical advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract.
Aetna arranges for the provision of health care services. However, Aetna itself is not a provider of health care services, and therefore,
cannot guarantee any results or outcomes.
Consult the plan documents (Schedule of Benefits, Certificate of Coverage, Evidence of Coverage, Group Agreement, Group
Insurance Certificate, Booklet, Booklet-certificate, Group Policy) to determine governing contractual provisions, including procedures,
exclusions and limitations relating to the plan.
These plans contain exclusions and some benefits are subject to limitations or visit maximums.
While this material is believed to be accurate as of the print date, it is subject to change.
05.03.321.1 (10/04)
Available in Spanish. Disponible en Español.
©2004 Aetna Inc.
For additional information about your
benefits, claims, the Preferred Drug List,
prescription medication cost estimates,
and more, register on the Aetna
Navigator™ secure member website at
www.aetna.com. You can also refer to
your summary of benefits or call us at
the toll-free number on your Aetna
member ID card.
We’ll be happy to help!
Log onto www.aetnapharmacy.com
today to learn about hundreds of
prescription medications, possible sideeffects, potential drug interactions,
generic substitutions, tips on how to
save money, drug safety, and more.