Prescription Drugs

Aetna is the Pharmacy Benefit Manager and prescription drug coverage is included in the UM/Aetna medical plan. Once enrolled in the UM/Aetna medical plan, you will receive your ID card. This card should be used when picking up your prescriptions. Aetna's in-network pharmacies include Walgreens, CVS, Publix, Walmart, and many others – 68,000 pharmacies nationwide.

Four-Tier Structure

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  • Four-Tier Structure

    Each medical plan covers the same prescription drugs, and costs are determined by the four-tier structure below. If the cost of the prescription is less than the copay, you pay the lesser amount. In the HRA plan, prescription copays apply only after you have met your deductible. Formulary changes occur throughout the year. 

    Medications may move up or down a tier throughout the plan year. These changes can occur because of the availability of new medications or if the FDA makes a new recommendation about an existing medication. 

    Note, any prescription NOT covered by Aetna is the full responsibility of the member and WILL NOT be applied toward your deductible or out-of-pocket maximum.

    Tier Cost Description
    Tier 1 $10

    Covered preferred generic medications (not self-injectable)
    G = Generics 
    Tier 2 $45

    Covered preferred brand name medications (not self-injectable)
    PB = Preferred Brands 
    Tier 3 $75

    Covered non-preferred generic and brand-name medications (not self-injectable)
    NPB = Non-Preferred Brands 
    Tier 4 $100

    Preferred and non-preferred self-injectable drugs covered by prescription benefits. Insulin is covered under Tiers 1, 2, and 3 (tier depends on type)
    NPSP = Non-Preferred Specialty 
    PSP = Preferred Specialty

    CE = Copay Exception; available to some members at no cost with a prescription from your provider when obtained at an in-network pharmacy. Certain limitations may apply. 
    NF = Non-formulary, not covered unless exception request granted

  • Formulary Medications

    To verify if a medication is covered under your UM/Aetna plan:

    1. Log into your secure Aetna account.
    2. Once logged in, click Plan Overview on the purple header, then under Pharmacy, click What's Covered.
    3. Under Estimate Medication Costs, enter the name of the medication and the dosage, if applicable, then select the correct medication.
    4. You will be redirected to a new page which lists the medication details, as well as estimated cost.

     

    Note, any prescription NOT covered by Aetna is the full responsibility of the member and WILL NOT be applied toward your deductible or out-of-pocket maximum.

Helpful Definitions

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  • Generic Drugs

    Generic drugs contain the same active ingredients in the same amounts as the brand-name drugs and work the same way. They are proven to be just as safe and effective as brand-name drugs. So they have the same risks and benefits as brand-name drugs do. However, generic drugs typically cost less. When appropriate, your doctor may decide to prescribe a generic drug, or allow the pharmacist to substitute a generic drug. A generic drug is the same as a brand-name drug in: 

    • Dosage
    • Safety
    • Strength
    • Quality
    • The way it works
    • The way it is taken
    • The way it should be used

     

    Compared with brand-name drugs, generic drugs may: 

    • Be a different color, shape or size
    • Have different fillers, binders, coloring agents and flavorings (these are called "inactive ingredients")

     

  • Maintenance Medications

    Maintenance drugs are prescriptions commonly used to treat conditions that are considered chronic or long-term. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are those used to treat high blood pressure, heart disease, asthma, and diabetes.

  • Precertification

    Precertification is one way that we can help you and your doctor find safe, appropriate drugs and keep costs down.

    Precertification means that you or your doctor need to get approval from the plan before certain drugs will be covered. Generally, precertification applies to drugs that: 

    • Are often taken in the wrong way
    • Should only be used for certain conditions
    • Often cost more than other drugs that are proven to be just as effective

  • Quantity Limits

    Quantity limits help your doctor and pharmacist make sure that you use your drug correctly and safely. 

    Aetna uses medical guidelines and FDA-approved recommendation from drug makers to set these coverage limits. The quantity limit program includes:

    • Dose efficiency edits - Limits prescription coverage to one dose per day for drugs that have approval for once-daily dosing. 
    • Maximum daily dose - If a prescription is less than the minimum or higher than the maximum allowed dose, a message is sent to the pharmacy. 
    • Quantity limits over time - Limits prescription coverage to a specidic number of units over a specific amount of time. 

  • Specialty Pharmacy

    The network specialty pharmacy fills prescriptions for specialty drugs. These types of drugs may be injected, infused or taken by mouth. Usually, you can't get these drugs at a local retail pharmacy. They often need special storage and handling, and they need to be delivered quickly. 

    • Free, secure delivery (typically within 48 hours of confirming your order)
    • Delivery to your home, doctor's office or any other place you choose
    • Package tracking for prompt delivery
    • Training on how to self-inject your medicine
    • Flexible payment options
    • Free injection supplies, such as needles, syringes, alcohol swabs, adhesive bandages and containers for needle waste

  • Step Therapy

    Some drugs require step therapy. This means that you must try one or more other drugs before a step therapy drug is covered. 

    The other drugs are called prerequisite drugs. They are equally effective, have FDA approval and may cost less. They treat the same condition as the step therapy drug. 

    If you don't try the other drugs first, you may need to pay full cost for the step therapy drug. 

Maintenance Medications

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  • Maintenance Medications

    If you are taking a maintenance medication, any medication taken in the same strength and dosage for more than 90 days, you can save money and avoid a penalty by filling your prescription in a 90-day supply at any in-network pharmacies such as Walgreens, Walmart, Publix, CVS retail pharmacy, or CVS Caremark®.

    If you fill your maintenance medications monthly (in 30-day increments), your copayment will increase by 2½ times after the second filled 30-day prescription. 

    Tier 2 Rx Example

    Local retail pharmacy
    (monthly cost, 30-day supply)

    		 Local Retail Pharmacy or
    CVS Caremark® Mail
    Service (average monthly cost, 90-day supply)
    First 30-Day Fill $45.00 $37.50
    30-Day Refill #1 $45.00 $37.50
    30-Day Refill #2 $112.50 $37.50

    NOTE: Cost increase reflects permanent change in copay for this and all additional refills of the same medication for 30-day supplies at local retail pharmacy. 90-day supplies can be obtained at any local retail pharmacy or CVS Caremark® Mail Service.

  • In-Network Pharmacies

    If you are taking a maintenance medication, any medication taken in the same strength and dosage for more than 90 days, you can save money and avoid a penalty by filling your prescription in a 90-day supply at any in-network pharmacies such as Walgreens, Walmart, Publix, CVS retail pharmacy, or CVS Caremark®.

    Click here to access Aetna's pharmacy finder.

On Campus Pharmacies

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Pre-Certification

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  • Pre-Certification (Prior Authorization)

    Based on FDA guidelines and current medical findings, precertification supports member safety and appropriate drug use, and helps keep health care costs manageable by requiring certain conditions for coverage. Generally, precertification applies to drugs that: 

    • Are often taken in the wrong way
    • Should only be used for certain conditions
    • Often cost more than other drugs that are proven to be just as effective

    To verify if a medication is covered under your UM/Aetna plan:

    1. Log into your secure Aetna account.
    2. Once logged in, click Plan Overview on the purple header, then under Pharmacy, click What's Covered.
    3. Under Estimate Medication Costs, enter the name of the medication and the dosage, if applicable, then select the correct medication.
    4. You will be redirected to a new page which lists the medication details, as well as estimated cost.

     

    Note, any prescription NOT covered by Aetna is the full responsibility of the member and WILL NOT be applied toward your deductible or out-of-pocket maximum.

  • How to Request Pre-Certification

    • You or your doctor can call the Aetna Pharmacy Precertification Unit at 1-800-414-2386. 
    • You can log in to your secure member website and submit a request through the Contact Us feature. 
    • You or your doctor can fill out a request form and send it to Aetna:
      • By fax to 1-877-269-9916
      • Through the provider portal on Availity - only your doctor can use this option
      • By mail to:
    Aetna Pharmacy Management
    1300 East Campbell Road
    Richardson, TX 75081 

     

    Medical Exception/Prior Authorization/Precertification* Request for Prescription Medications

Specialty Pharmacy

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  • Get Started

    The network specialty pharmacy fills prescriptions for specialty drugs. These types of drugs may be injected, infused or taken by mouth. Usually, you can't get these drugs at a local retail pharmacy. They often need special storage and handling, and they need to be delivered quickly. 

    • Free, secure delivery (usually within 48 hours of confirming your order)
    • Delivery to your home, doctor's office or any other place you choose
    • Package tracking for prompt delivery
    • Training on how to self-inject your medicine
    • Flexible payment options
    • Free injection supplies, such as needles, syringes, alcohol swabs, adhesive bandages and containers for needle waste

     

    Specialty medications may be filled at UHealth Specialty Pharmacy, Walgreens, CVS Specialty, or any pharmacy in the open specialty network.

    Aetna has several ways for you to fill a prescription through the network specialty pharmacy. For a new prescription, your doctor can: 

    • e-Prescribe NCPDP ID 1466033
    • Fax your prescription to 1-800-323-2445
    • Call 1-800-237-2767

  • Specialty Pharmacy Medications

    A specialty medication is one that:

    • Requires extra attention from your health care team
    • May treat a rare, serious, or chronic condition
    • May be expensive
    • May be given orally or by injection

     

    To verify if a medication is covered under your UM/Aetna plan:

    1. Log into your secure Aetna account.
    2. Once logged in, click Plan Overview on the purple header, then under Pharmacy, click What's Covered.
    3. Under Estimate Medication Costs, enter the name of the medication and the dosage, if applicable, then select the correct medication.
    4. You will be redirected to a new page which lists the medication details, as well as estimated cost.

     

    Note, any prescription NOT covered by Aetna is the full responsibility of the member and WILL NOT be applied toward your deductible or out-of-pocket maximum.

Step Therapy

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  • What is Step Therapy?

    Some drugs require step therapy. This means that you must try one or more other drugs before a step therapy drug is covered. 

    The other drugs are called prerequisite drugs. They are equally effective, have FDA approval and may cost less. They treat the same condition as the step therapy drug.  

    If you don't try the other drugs first, you may need to pay full cost for the step therapy drug. 

  • Step Therapy Medications

    To verify if a medication is covered under your UM/Aetna plan:

    1. Log into your secure Aetna account.
    2. Once logged in, click Plan Overview on the purple header, then under Pharmacy, click What's Covered.
    3. Under Estimate Medication Costs, enter the name of the medication and the dosage, if applicable, then select the correct medication.
    4. You will be redirected to a new page which lists the medication details, as well as estimated cost.

     

    Note, any prescription NOT covered by Aetna is the full responsibility of the member and WILL NOT be applied toward your deductible or out-of-pocket maximum.

Additional Resources

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  • CVS Caremark® Mail Service

    CVS Caremark® Mail Service is a fast and convenient way to get the medicines you need. And it's included with your pharmacy benefits and insurance plan. New orders or renewals will need to be submitted to the CVS Caremark® mail service. To start home delivery: 

    Ask your doctor to write two prescriptions for your maintenance drug: 

    • A 30-day supply to fill at your local pharmacy
    • A 90-day supply with three refills. Fill out the order form and mail or fax it to us with your prescription and payment. The return address is on the form. The fax number is 1-877-270-3317.

     

    Mail Service Order Form (English)
    Mail Service Order Form (Spanish)

  • Frequently Asked Questions

    Click here to review questions and answers about pharmacy coverage.

  • Non-Covered Medications

    In certain circumstances,* you or your prescriber can request a medical exception for a non-covered drug. To submit a request for a medical exception:

    • Call the Precertification Department at 1-855-582-2025
    • Fax a request to 1-855-330-1716
    • Mail a request to CVS Health, Attn: Aetna PA, 1300 E. Campbell Rd., Richardson, TX 75081

     

    If the request is expedited a coverage determination will be made within 24 hours of receiving the request, and notify you or your prescriber of our decision. All medically necessary outpatient prescription drugs will be covered. If a medical exception is approved the member is responsible for the highest applicable copay after deductible depending upon the members pharmacy plan design.

    *These circumstances exist when you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, or undergoing a current course of treatment using a non-covered drug.

  • Prescription Drug Claim Form

    Prescription Drug Claim Form 

    Submission Requirements:
    You MUST include all original pharmacy receipts in order for your claim to process. Cash register receipts WILL NOT be accepted with the exception of diabetic supplies. The minimum information that must be included on your pharmacy receipts is listed below:

    • Patient Name
    • Prescription Number
    • Medicine NOC number
    • Date of Fill
    • Metric Quantity
    • Total Charge
    • Days Supply for your prescription (you need to ask your pharmacist for this "Day Supply" information)
    • Pharmacy Name and Address or Pharmacy NABP Number

Questions?

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