Prescription Drug Coverage

All of our medical plans offer a retail program for short-term medications as well as a mail order program for medications you take on an ongoing or daily basis. Prescription drugs are covered only when you use a network retail pharmacy or the mail order program.

Your cost for prescription drugs depends on the whether your medication is a generic, preferred brand, or non-preferred brand drug. Aetna uses a Prescription Drug List (PDL) (also known as a formulary) to determine which category a prescription drug falls under. This is a comprehensive list of approved generic and brand name prescription drugs to assist physicians in prescribing quality, reasonably priced medications. The list is updated quarterly and is subject to change. View Aetna's Prescription Drug List and updates as of April 1, 2025, July 1, 2025, and October 2025.

In addition, Aetna classifies certain medications as “preventive.” Preventive medications are covered differently at the pharmacy as shown below. View Aetna’s Preventive Drug List.

Your prescription drug copays and coinsurance count toward meeting your medical plan's deductible and out-of-pocket maximum.

Network Retail Pharmacies (up to a 31-day supply)

For preventive drugs (drugs on Aetna’s Preventive Drug List): Your deductible is waived and you pay the applicable copay or coinsurance amounts below until your out-of-pocket maximum is satisfied, then the plan pays 100%. Minimum and maximum amounts, where applicable, are per prescription.
- Generic: You pay $10 copay
- Preferred brand: You pay 25% ($25 minimum, $75 maximum)
- Non-preferred brand: You pay 40% ($40 minimum, $100 maximum)
For non-preventive drugs (drugs not on Aetna’s Preventive Drug List): You pay the full cost of the medication until your annual deductible is satisfied, then you pay the applicable copay or coinsurance amounts above until your out-of-pocket maximum is satisfied, then the plan pays 100%.

Mail Order (90-day supply)

For preventive drugs (drugs on Aetna’s Preventive Drug List): Your deductible is waived and you pay the applicable copays or coinsurance amounts below until your out-of-pocket maximum is satisfied, then the plan pays 100%.
- Generic: You pay $25 copay
- Preferred brand: You pay 25% ($50 minimum, $150 maximum)
- Non-preferred brand: You pay 40% ($80 minimum, $200 maximum)
For non-preventive drugs (drugs not on Aetna’s Preventive Drug List): You pay the full cost of the medication until your annual deductible is satisfied, then you pay the applicable copay or coinsurance amounts above until your out-of-pocket maximum is satisfied, then the plan pays 100%.

How to request a mail order prescription drug

To begin using the mail order program:

Call Aetna at the phone number on your ID card, log in to Aetna's website, or download the Aetna Health app.
Request mail service by phone or online. You can also print out and complete the mail order form and send it to Aetna.
Request refills online, by phone, or by mail.

Additional Plan Features

Medications that are free to you

Certain medications, oral contraceptives and contraceptive devices, and tobacco cessation medications are available at no cost to you as identified on Aetna's Health Care Reform Drug List.

Quantity limits for certain medications

Certain medications have a quantity limit on how much can be dispensed each time the prescription is filled. You will be notified if this is the case for your prescription.

Prior authorization

Certain medications require prior authorization from Aetna before they are covered. Prior authorization focuses on drugs that have risks of side effects or drug interactions, potential for incorrect use or abuse, or alternatives that may cost you less and work better. These drugs need to be reviewed by Aetna before they are covered to make sure they are safe and affordable to you.

Aetna determines which drugs require prior authorization through a committee of doctors and pharmacists who do not work for the health plan. This group bases their decisions on drug safety, how well the drug works, and the value. If you are taking a drug that requires prior authorization, your doctor or pharmacist will work directly with Aetna to obtain approvals. The process usually takes 24 to 48 hours.

To find out what prescription drugs require notification, you may call customer service at the number on your medical ID card.

Specialty medications

Specialty medications are those that have high cost; have a special method of being administered, such as injection or infusion; treat rare, unusual or complex diseases; or require additional clinical oversight and expertise. Specialty medications must always be filled at a CVS Specialty Pharmacy.

Specialty medications are managed by PrudentRx, who works with drug manufacturers to keep your costs down through manufacturer copay card assistance. For specialty medications that are listed on PrudentRx's Specialty Drug List, you pay 30% until you meet your deductible, then the plan will cover it in full. Specialty medications that are not covered on the PrudentRx list will process at regular plan copays and coinsurance amounts. Refer to the PrudentRx Specialty Drug List to see if a drug is covered, or call PrudentRx at 800-578-4403 Monday-Friday, between 8:00am and 8pm Eastern Time.