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The formulary (list of covered drugs) will tell you:
The drugs we cover
The tier a drug is on
Any limits or requirements before we cover the drug
If the drug is eligible for home delivery
Estimate your out-of-pocket costs for your drugs
Changes to the formulary (list of covered drugs)
We review our drug list on a monthly basis and make changes as necessary. Most changes are positive. An example would be adding new generics that have come on the market.
Sometimes we have to remove a drug from our formulary. An example is if the U.S. Food and Drug Administration (FDA) says a drug is unsafe or the drug maker takes the drug off the market.
Prior authorization, quantity limits & step therapy
Some drugs have rules you need to follow before we cover them. These include:
Prior authorization: You or your doctor must get approval from us before we cover the drug.
Step therapy: We require you to try another drug first before we cover your drug.
Quantity limits: For certain drugs, we limit the amount you can get.
You and your doctor can ask us to make an exception to one of our coverage rules. This includes requesting an exception to a prior authorization, step therapy or quantity limit rule.
There may be times where you’re taking a drug that either isn’t on our drug list or has special rules before we cover it. Learn about our transition process to see if you’re eligible for a short-term supply of medication while you move to a drug we do cover. This temporary supply allows you to work with your doctor to either transition to a new drug or request an exception to continue your current drug.
Please note that following this link will take you to a public Aetna site and not all links on this public page will apply to your Medicare Advantage plan.