Prescription Drugs

As an Aetna plan member, your plan includes coverage for Part D prescription drugs. Aetna has a formulary also called a list of drugs and has consulted with team of health care providers to develop the formulary. It includes prescription therapies believed to be a necessary part of a quality treatment program. Some covered drugs may have restrictions or limitations. The Aetna Medicare Advantage Dual Eligible Special Needs plan generally covers the drugs listed in our formulary as follows:

The drug is medically necessary,
The prescription is filled at an Aetna network pharmacy
Other plan rules are followed

This section provides information about the prescription drug benefits covered by Aetna Aetna Medicare Advantage Dual Eligible Special Needs plan. This section also provides information about coverage limitations that may apply to some covered drugs. You can also learn about our Medication Therapy Management Program.

Prescription drugs are often an important part of managing a health issue. For your peace of mind, it helps to know that a drug you take is paid for. You can find out by reading our formulary. A “formulary” is a list of drugs we cover and any costs you may have to pay.

If you need a drug that is not on the List of Covered Drugs (formulary), your prescriber must provide a statement that says you have tried the formulary medications and they did not work for you, or a medical reason why you cannot try the formulary medications.

Your Aetna formulary is below. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. If you have any questions about a drug that is not listed, please call Member Services at 1-855-463-0933 (TTY: 711) 8 AM to 8 PM, seven days a week.

Formulary, Formulary Updates and search tool

Find out if your medicine is covered
The formulary below lists the drugs covered by Aetna. A formulary is just another name for a prescription drug list. We consulted with a team of health care providers to develop this list. It includes prescriptions we believe are needed in a quality treatment program.

We generally cover the drugs in our formulary as long as:

‒ The drug is needed to treat an illness or injury

‒ Your prescription is filled at a pharmacy in our network

‒ You follow any other plan rules that apply

View the 2022 Prescription Drug Search Tool or the 2023 Prescription Drug Search Tool

View the List of Covered Drugs

View the monthly formulary updates

You can get this information for free in other languages. Call 1-855-463-0933 (TTY: 711) 8 AM to 8 PM, seven days a week. The call is free. And you can contact us for the most recent list of drugs at 1-855-463-0933 (TTY: 711) 8 AM to 8 PM, seven days a week.

Pharmacy search tool

View the 2022 Pharmacy Search tool or the 2023 Pharmacy Search tool.

When can you use a pharmacy that is not in the plan’s network?
Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. To help you, we have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. If you cannot use a network pharmacy, there are certain circumstances when we would cover prescriptions filled at an out-of-network pharmacy. Please refer to your Evidence of Coverage for information about when we will cover a prescription filled at an out-of-network pharmacy. Please check first with Member Services to see if there is a network pharmacy nearby. You may be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at an in-network pharmacy. If you must use an out-of- network pharmacy, you will generally have to pay the full cost rather than your normal share of the cost at the time you fill your prescription. You can ask us to reimburse you for our share of the cost.

Mail-order Services

Your plan has a home delivery option for prescription drugs. Most prescription drugs are available through our Rx mail order pharmacy, CVS Caremark^® Mail Service Pharmacy. This may be a great option if you take medications regularly.

CVS Caremark^® Mail Service Pharmacy is convenient and may help you save money.

Your drugs will be delivered to your door. Or you may choose other locations.
You can get up to a 90-day supply for most medications.

Some medications aren’t available through CVS Caremark^® Mail Service Pharmacy. To see which drugs are available, check your plan formulary (drug list) or call us at the number on your ID card. The drugs available through our plan’s mail-order service are marked as “mail-order” drugs in our Drug List or MO.

You can call us toll free at the number on your member ID card or by completing this form (English | Spanish):

CVS Caremark Mail Service Pharmacy

PO BOX 94467

PALATINE, IL 60094-4467

Let us know how you want to pay for your order. That way you can avoid processing delays. You have options such as all major credit and debit cards, electronic check and more. Call us to learn more about your options.

Once we receive your order:

We’ll check to make sure we have all the information we need to process your order. We’ll contact you or your doctor if we need additional information.

If your order is for a new prescription:

And you ordered it yourself, we’ll ship it as soon as it’s processed. Just make sure we have your payment information on file to avoid delays.

And your doctor gave us a script, we’ll need your approval to ship it unless you have a history of using our home delivery service in the past 12 months. If you do, we’ll ship your order as soon as it’s processed.

If your order is a refill:

And you ordered it yourself, we’ll ship it as soon as it’s processed. Just make sure we have your payment information on file to avoid delays.

CVS Caremark^® Mail Service Pharmacy order standardly arrives within 7 to 10 days after we process your order.

Keep in mind: Some prescriptions require you to sign for the delivery. Call us to learn if your drug requires a signature upon delivery.

Prior Authorization

Sometimes you (or your doctor) need to get prior authorization for certain drugs. This means that you need to get approval from the plan before you fill these prescriptions. If you don’t, Aetna may not cover the drug.

Learn more about Prior Authorization Criteria.

Visit the 2022 Prescription Drug Search Tool or the 2023 Prescription Drug Search Tool or contact us for the most recent list of drugs at 1-855-463-0933 (TTY: 711) 8 AM to 8 PM, seven days a week.

Non-formulary Requests:

Step Therapy

Sometimes we need you to try certain drugs first to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Aetna may not cover Drug B unless you try Drug A first. If Drug A doesn’t work, Aetna then covers Drug B.

Learn more about the Step Therapy Criteria.

Quantity limit

Aetna generally covers the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Aetna^® network pharmacy, and other plan rules are followed.

View the 2022 Prescription Drug Search Tool or the 2023 Prescription Drug Search Tool
View the List of Covered Drugs

Request an exception to the formulary and coverage decisions

Can you ask for an exception to cover your drug?
Yes. You can ask Aetna to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug.

For example, Aetna may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more.
Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.

How long does it take to get an exception?
First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber’s supporting statement.

How can you ask for an exception?
To ask for an exception, call Member Services at 1-855-463-0933 (TTY: 711) 8 a.m. to 8 p.m., 7 days a week. A Member Services representative will work with you and your provider to help you ask for an exception.

Download the Prior Authorization Form (PDF)

Drug Coverage Determination Form

This form may be sent to us by mail or fax:

Mail:
Aetna
Part D Coverage Determination
Pharmacy Department
4500 E. Cotton Center Blvd.
Phoenix, AZ 85040

Fax: 1-877-270-0148

You may also ask us for a coverage determination by phone 1-855-463-0933 or through our website. We are available 8 AM to 8 PM, seven days a week. TTY users should call 711.

Fill out the Coverage Determination Form.

Who may make a request: Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative.

Drug Coverage Redetermination Form

Request for redetermination of Medicare prescription drug denial
If Aetna denies your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our "Notice of Denial of Medicare Prescription Drug Coverage" to ask us for a redetermination. This form may be sent to us by mail or fax:

Mail:
Aetna

Part D Appeals
Pharmacy Department
4500 E. Cotton Center Blvd.
Phoenix, AZ 85040

Fax: 1-877-270-0148

You may also ask us for an appeal through our website. Expedited appeal requests can be made by phone 1-855-463-0933.

Fill out the Coverage Redetermination Form.

Who may make a request: Your prescriber may ask us for an appeal on your behalf. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. Contact us to learn how to name a representative.

Prescription Drug Transition Policy

When you change health plans, you may find you now have different benefits. You also may have different drug coverage. We want to make your transition easy for you.

If you join our plan and find out we don’t cover a prescription drug you’ve been taking, let us know. You may be on drugs that aren't on our drug list or covered with added requirements or limits.

Talk with your doctor

Your doctor can help you decide if you should switch to a covered drug or request a drug exception. It may help to share your formulary with your doctor. In the meantime, we may cover a temporary supply of your drug in certain cases during your first 90 days. You may be able to get at least a one-time fill of a 30-day (or less, as prescribed, up to a 30-day supply) supply of that drug at retail pharmacy.

This gives you a chance to work with your doctor to find a new treatment plan and avoid disruption. This process is called Prescription Drug Transition Policy/Transition of Coverage (TOC). Learn about how the prescription drug transition policy works.

After your 30-day transition supply, we won't pay for these drugs unless you get approval for a drug exception.

If you have questions or would like more information about our transition policy, please call Member Services toll-free at 1-855-463-0933 (TTY: 711) 8 AM to 8 PM, seven days a week.

Low-Income Subsidy (LIS) Information

The Low-Income Subsidy (LIS) Program, also called “Extra Help” helps cover the cost of prescription drugs for people with low incomes who are eligible for the Medicare Part D program. If you are enrolled in an Aetna Medicare Advantage Dual Eligible Special Needs plan in Virginia, you were sent a copy of either the 2022 Low Income Subsidy (LIS) Rider or the 2023 Low Income Subsidy (LIS) Rider that explains your Part D prescription drug cost sharing responsibilities.

Best Available Evidence

CMS Best Available Evidence (BAE) information.

Long Term Care Pharmacies (LTC)

LTC pharmacies are included in the network. These pharmacies offer pharmacy services to patients that are housed in a type of group home like a Nursing home or Rehabilitation center. Generally all LTC pharmacies are in network. LTC pharmacies will fill prescription orders written by medical staff in the group home and deliver the medication directly to the medical staff who will distribute the medication to the members. Generally, each group home will have one or two LTC pharmacies that supply most of the pharmacy services to all of the members residing in the facility.

To get information about filling your prescriptions at an LTC Pharmacy please call Member Services at 1-855-463-0933 (TTY: 711) 8 AM to 8 PM, seven days a week.

Home Infusion Pharmacies (HI)

Home infusion pharmacies are included in the network. These pharmacies supply drugs that may need to be given to you by an intravenous route or other non-oral routes, such as intramuscular injections, in your home.

To get information about filling your prescriptions at a Home Infusion Pharmacy please call Member Services at 1-855-463-0933 (TTY: 711) 8 AM to 8 PM, seven days a week.

Prescription Drugs

Request for Medicare prescription drug coverage determination

You are now leaving Aetna