In the event there are 2 or more alternative Medical Services which in the sole judgment of
Aetna are equivalent in quality of care, Aetna reserves the right to provide coverage only for the least costly MedicalService, as determined by Aetna, provided that Aetna pre-authorizes the
MedicalService or treatment.
Determinations regarding eligibility for benefits, coverage for services, benefit denials and all other terms of this Certificate are at the sole discretion of Aetna, subject to the terms of this
Certificate.
6.
Outpatient Prescription Drugs
How the Pharmacy Plan Works
It is important that you have the information and useful resources to help you get the most out of your
Aetna Prescription Drug plan. This Certificate explains:
How to access Network Pharmacies and procedures you need to follow;
What Prescription Drug expenses are covered and what limits may apply;
What Prescription Drug expenses are not covered by the plan;
How you share the cost of your covered Prescription Drug benefit; and
Other important information such as eligibility, complaints and appeals, termination, and general administration of the plan.
A few important notes to consider before moving forward:
Unless otherwise indicated, “you” refers to you and your covered dependents.
Your Prescription Drug plan pays benefits only for Prescription Drug expenses described in this Certificate as Covered Benefits that are Medically Necessary.
This Certificate applies to coverage only and does not restrict your ability to receive
Prescription Drugs that are not or might not be covered benefits under this Prescription Drug
plan.
Store this Certificate in a safe place for future reference.
Notice
The plan does not cover all Prescription Drugs, medications and supplies. Refer to the Limitations section of this coverage and Exclusions section of your Certificate.
Covered Benefits are subject to cost sharing requirements as described in the cost sharing sections of this coverage and in your Schedule of Benefits.
Specialty Prescription Drug refills will only be covered when obtained throughAetna’s
Specialty Network Pharmacy.
This plan covers only certain Prescription Drugs in accordance with the plan and the Preferred Drug Guide (Formulary). This plan does not cover all Prescription Drugs.
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Accessing Pharmacies and Benefits
When you obtain prescription medications from a retail pharmacy, you will pay your portion of the cost as stated in your medical benefits brochure. Please consult your current provider directory for the names of pharmacies.
If you use a non-participating pharmacy, you must pay retail price at the time of purchase and submit a reimbursement form to Express Scripts. To obtain forms and instructions for reimbursement, contact Customer Service or click “Prescription Documents” in the Members section of our website at www.Aetna.com. Reimbursement will be equal to the eligible medical expense less your applicable copay, coinsurance and/or deductible. You will not be reimbursed the difference between retail price and the eligible medical expense, which is based on Aetna’s contracted rate for the medication.
If you need prescription medications while you are outside our Idaho service area, contact Customer Service or use our pharmacy locator link on the Members section at www.Aetna.com for the nearest pharmacy.
In order for your prescription to be covered, you must present your ID card at a pharmacy. Coverage is subject to the limitations and exclusions in this handbook and your medical benefits brochure.
You may fill up to a 30-day supply of prescribed medications, but you may receive less as determined by federal or state law, by quantity level limits we have established, or by the manufacturer’s package size. When a copayment is required, you will pay one copayment for each prescription drug unit filled, even if your prescription provides less than a 30-day supply.
Some medications have specific limits on how much of the medication you can receive with each prescription or refill to ensure that you get the recommended and proper dose and length of drug therapy for your condition. Quantity level limits are reviewed by our Pharmacy and Therapeutics Committee and are based on factors such as the maximum dosage levels indicated by the drug manufacturer and the FDA, and the cost of the drug compared to a therapeutically equivalent alternative. You or your physician must obtain prior authorization for any amount of your prescription that exceeds quantity level limits. If authorization is granted, you may be required to pay an additional copayment.
If your physician prescribes a medication that needs to be dispensed in two different strengths or dosage forms, each will be dispensed as a separate prescription. You will be responsible for the appropriate prescription drug copayment or coinsurance for each dispensed prescription.
Certain covered medications and pharmaceutical products are manufactured or packaged in such a way as to provide greater than a 30-day supply of medication. These may require one copayment for each month of the anticipated duration of the medication. For example, if you receive a covered medication or pharmaceutical product that has a duration of two months, you will pay two prescription drug copayments.