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Drug coverage information: Understand your plan requirements

Depending on your plan, you may have to meet certain requirements before some drugs will be covered. These requirements include precertification, step therapy and quantity limits. Also, we provide a service to detect any therapeutic duplication in your prescriptions. All of this helps you avoid unnecessary health risks and helps to make sure you are getting the most cost-effective treatment.

If precertification, quantity limits or step therapy apply to your plan, simply log in to Aetna Navigator and use the Medication Search to see if your medications are affected.

Therapeutic duplication services are provided for all plans.

 

Learn more about these requirements: 

  • Therapeutic duplication 
  • Precertification 
  • Step therapy 
  • Quantity limits

 

Therapeutic duplication  

Avoid health risks from duplicate prescriptions

It is important to us that you and your doctor have access to all the information you need so you can be your healthiest and get the most value from your plan.

That's why our systems screen new claims and compares them against your claims history. We look for situations that may be of danger to your health.

Therapeutic duplication can occur when two doctors prescribe similar medications or when your doctor switches from one drug to another drug in the same class without cancelling the first prescription. If we detect such unsafe health risks, we'll bring it to your doctor's or pharmacist's attention.

No need to act. We provide this service automatically for all of our members who have pharmacy benefits.

 

Precertification 

Get prior approval for certain medications

Some plans may require your doctor to request prior approval (called precertification) from Aetna before certain medications will be covered. This encourages appropriate and cost-effective use of medications by allowing coverage only when certain conditions are met.

Reasons for precertification include age or gender of the member if outside of recommended dosing guidelines, duplicate therapies and to help health-care providers check that a medication is being used based on generally accepted medical criteria.

The precertification program is based on current medical findings, FDA-approved manufacturer labeling information and cost and manufacturer rebate arrangements.

Search the Preferred Drug List to see if your medications require precertification. Simply log in to Aetna Navigator and click on the "Medication Search" link to get information that is specific to your prescription drug plan.

  • Your doctor must contact Aetna to request approval for coverage of those medications listed as requiring precertification.
  • If we approve the request, we will notify your doctor. The medication will then be covered at the applicable copay under your plan. You will also be notified of approvals where states require it.
  • If the request is denied, you and your doctor will be notified. You can still purchase the medication for the full price or talk to your doctor about alternatives that may be covered under your pharmacy plan.


Step therapy  

For certain drugs, trying one or more prerequisite drugs is required before they may be covered under your plan. This promotes the appropriate use of equally effective but lower-cost drugs first. Your doctor can ask for an exception if it is medically necessary for you to use a step-therapy drug. Prerequisite drugs are FDA approved and treat the same condition as the corresponding step-therapy drugs.
 

Quantity limits  

The precertification program also limits coverage of quantities for certain drugs. These limits help your doctor and pharmacist check that the medications are used appropriately and it improves patient safety. We use medical guidelines and FDA-approved recommendations from drug makers to set these coverage limits. The quantity limit program includes:

  • Dose efficiency edits - Limits coverage of prescriptions to one dose per day for drugs that are approved for once-daily dosing.
  • Maximum daily dose - A message is sent to the pharmacy if a prescription is less than minimum or higher than the maximum allowed dose. 
  • Quantity limits over time - Limits coverage of prescriptions to a specific number of units in a defined amount of time.

To get prescription coverage for amounts that are over the allowed quantity, your doctor must request a medical exception.

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