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Changes to Your Prescription Drug Coverage for 2011
Thank you for being an Aetna member. We value your membership and want to help you get the most from your pharmacy benefits coverage. Below are details about upcoming plan changes and drug safety updates. Changes to our Preferred Drug List (also called the formulary) are based on the latest medical findings as well as information from the Food and Drug Administration (FDA) and drug makers. What’s changing? The drugs on our Preferred Drug List are chosen based on sound medical data, safety and cost. For 2011, we are adding some brand-name and generic drugs while other drugs are being removed. One reason changes may happen is when a brand-name drug’s patent expires during the year and a generic becomes available. We remove the brand from the list and replace it with its less-costly generic equivalent. To help encourage appropriate, safe and cost-effective drug therapy, we are also enhancing your plan’s precertification, quantity limits and step-therapy programs. The enclosed chart shows the changes that will begin January 1, 2011.1,2,3,4 If your prescriptions are affected by any of these updates, the amount you pay for these drugs may also change. Talk to your doctor about your treatment options. Ultimately, you and your doctor are responsible for making decisions about your drug therapy. Why some drugs are preferred Preferred drugs are generic and brand-name medications selected by our Pharmacy and Therapeutics Committee and Aetna Pharmacy Management for being the most clinically appropriate and cost effective treatment choices. These drugs go through a rigorous review process and are proven to be at least as effective and safe as other drugs taken for the same condition. In addition, these drugs are often available at a lower cost. This means that your copay or coinsurance—the amount you pay for a covered medication under your benefit plan— will likely be lower than the cost of non-preferred drugs. The following coverage tiers apply to your plan: Type of Medication Covered preferred generic drugs
Covered non-preferred generic and brand-name drugs
How to save on your prescriptions You may want to ask your doctor or pharmacist if generic drugs are right for you. Your savings with these drugs will depend on your plan and your prescriptions. Aetna Tip: Generics have the same active ingredients in the same dose as brand- name drugs. They just may have a different color or size. Your benefits in one place — Aetna’s Secure Member Website Don’t forget that you can learn more about your benefits online. Just go to www.aetna.com, register and log in. Then you can check your claims and see your benefit summary. You can also use our helpful tools: Price-A-Drug (Prescription Drug Costs) helps you look up what you pay for prescriptions. You can also see how much you could save by using generic drugs or getting your prescriptions through the mail, depending on your plan. Find-A-Pharmacy lets you find a nearby retail pharmacy in our network. Medication Search shows you how your prescription might be covered. You can also learn more about any additional coverage requirements. SmartSourceSM gives you personalized information about health issues, recommended prescriptions and approximate costs. Fill your prescriptions in any of our 60,000 pharmacies Many retail pharmacies take part in our wide pharmacy network. Use our Find-A- Pharmacy tool on www.aetna.com to find one near you. When you visit one of these locations, just show your Aetna ID card and pay your out-of-pocket cost. Aetna Tip: Bringing your Aetna ID to the pharmacy means you don’t have to fill out reimbursement forms. That way, you can use your pharmacy benefits right away.
With your well-being in mind Some prescriptions may have to meet certain requirements before they will be covered. Sign in to your secure member website and click on "Medication Search" to see if your prescriptions have these requirements. If they do, you’ll need to ask your doctor to contact us. Requirements Precertification2,3,4
Precertification promotes member safety. It applies to drugs that may easily be misused
or should only be prescribed for certain
conditions. It also helps manage healthcare
costs by requiring certain conditions for
coverage. To make a request, you may contact Aetna by phone, mail or online. If the request is not approved, you can still purchase the medication. However, you will have to pay full price.
Quantity Limits
We use medical guidelines and FDA-approved recommendations from
medication quantities that are greater than the coverage limits.
Step-Therapy3, 4
This practice promotes the appropriate use of equally effective
or more prerequisite drugs before a
for you to use a drug on the Step-Therapy List.
Therapeutic Duplication
Rarely are two drugs of the same type necessary to treat a medical condition.
Taking these drugs at once may be harmful
serious side effects. If duplication is identified, your doctor must contact Aetna to get approval for coverage.
How can I learn more about my coverage, medications and costs? See your plan documents for information about tiers as well as plan terms and limitations. If you have Internet access, you can visit us online to learn more about how and why our Preferred Drug List is changing. You can find the most current information about the Preferred Drug, Precertification, Quantity Limits and Step-Therapy Lists. Please note that these lists are subject to change throughout the year and are updated regularly online. Just go to www.aetna.com and click on “Medication Search.” In addition, you can help us in preserving our nation’s environmental resources by choosing to receive future updates and communications online. Just click on “Your Profile” and choose “Turn Off Paper.” Then type in your e-mail address. If you don’t have internet access and would like to receive a printed copy of the 2011 Preferred Medication Guide, please return the enclosed reply card. A guide will be mailed to you. Please contact us if you have any questions Send a secure e-mail from the “Contact Us” section at www.aetna.com. Or call the toll-free Member Services number on your Aetna ID card. 2011 Drug Coverage Changes Brand Name Medications added to the Preferred Drug List (* = may be added prior to 1/1/11) ADCIRCA
MIRAPEX ER *
NUCYNTA * Generic Medications added to the Preferred Drug List (Brand-name equivalents for drugs below will apply non-preferred copays on 1/1/11) anastrozoleazelastine (ASTELIN NASAL)Medications removed from the Preferred Drug List1 (Non-preferred copays will apply as of 1/1/11) ADVICOR Medications added to the Precertification List 2,3,4
EPIDUO PR ≥36 yr old Medications to be removed from the Precertification List (edit wil no longer apply) Medications added to the Quantity Limits List or changes to the Quantity Limit3,4
XIFAXAN 200mg (9/30 day) Medications to be removed from the Quantity Limit List (edit will no longer apply) Medications added to the Step-Therapy List3,4 AMERGE ++
ANDRODERM +
RETIN-A +
ARICEPT ++
ARICEPT ODT ++
LOTREL (5-40 mg, 10-40 mg) + XOPENEX HFA
COREG CR ++ + = Trial of a generic equivalent is required first ++ Step-therapy will not be implemented until sometime after generic equivalent becomes available Medications to be removed from the Step-Therapy List (edit will no longer apply) BROVANA New Benefit Exclusions
Any compounded drug if it includes an OTC or bulk powder ingredient (applies to fully-insured plans only) Cutis Pharmaceuticals products listed below (not FDA approved) FIRST-BXN MOUTHWASH
Discontinued Drugs- these products are no longer being manufactured (Please contact your physician for alternatives if you are taking one of the below products) AEROBID (June 2011)
Addition to Aetna Specialty Care Rx list UPPER CASE = brand name medication lower case italics = generic medication
Please note that if your prescription drug benefits plan changes, the information in this letter may no longer apply.
Aetna has established a policy to allow exceptions or overrides to certain refill-too-soon limitations. Requests for such exceptions or overrides will be evaluated on a case-by-case basis. "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 benefit 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. This material is for informational purposes only and contains only a partial, general description of plan benefits or programs and does not constitute a contract. Consult the plan documents (Schedule of Benefits, Certificate of Coverage, Evidence of Coverage, Group Agreement, Group Insurance Certificate, Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitations relating to the plan.
1 In accordance with state law, full-risk members in Texas who are receiving coverage for medications that are removed from the Preferred Drug List during the plan year will continue to have those medications covered at the same benefit level until their plan’s renewal date.
2 The term precertification means the utilization review process to determine whether the requested service, procedure, prescription drug or medical device meets the company's clinical criteria for coverage. It does not mean precertification as defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members.
3 In accordance with state law, California HMO members who are receiving coverage for medications that are added to the Precertification or Step-Therapy lists will continue to have those medications covered, for as long as the treating physician continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee's medical condition. Nothing in this section shall preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this section be construed to prohibit generic drug substitutions.
4 Some programs, such precertification, quantity limits and step-therapy are not available in all service areas and are subject to change. For example, precertification and step therapy programs do not apply to fully insured members in Indiana. Step-therapy does not apply to fully insured members in New Jersey. However, these programs are available to self-insured plans. Please refer to your plan documents or call the Member Services number on your ID card.
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