EPO Plan
Plan highlights
Prescription drug coverage
For more information
The EPO medical plan is an Exclusive Provider Organziation, which means all coverage is provided exclusively within the EPO network. There are no benefits for out-of-network care.
The plan is administered by Aetna.
- The EPO plan uses Aetna's EPO network of doctors, hospitals, and facilities. There are no benefits for out-of-network care. The name of the provider network is the Aetna Premier Care Plus Network (APCN+). Locate network providers.
- Preventive care is covered at 100%.
- For doctor visits and medications, you only pay a flat dollar copay and your annual deductible is waived.
- For all other services, you must meet a deductible before the plan pays for any of your medical care.
- After you meet your deductible, the plan pays 70% of your eligible medical care expenses and you pay 30%.
- The amount you pay for prescription drugs depends on whether they are generic, preferred brand, or non-preferred brand and if you obtain them through a retail pharmacy or through the mail order program. Certain medications and devices are available at no cost to you.
- When a family member meets the individual deductible, benefits will begin for that person. The family deductible can be met with any combination of expenses incurred by any family member, except that one person can never incur deductible expenses above the individual deductible limit.
- When you spend up to the out-of-pocket maximum, the plan will begin to pay 100% of all remaining covered charges for the rest of the year.
- Certain procedures and admissions require prior authorization (pre-service review) from Aetna so that they can be determined for medical necessity. Examples include, but are not limited to, MRI and other advanced imaging procedures, scheduled non-emergency hospital and residential treatment center admissions, transplant services, physical therapy and chiropractic services that exceed the plan's number of visits, and treatment for pervasive development disorder or autism.
The EPO Plan offers 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.
Your prescription drug copays count toward meeting your medical plan's deductible and out-of-pocket maximum.
Network Retail Pharmacies (up to a 31-day supply)
Your deductible is waived and you pay the applicable copays below until your out-of-pocket maximum is satisfied, then the plan pays 100%.
- Generic: $20 copay
- Preferred brand: $40 copay
- Non-preferred brand: $60 copay
Mail order (90-day supply)
Your deductible is waived and you pay the applicable copays below until your out-of-pocket maximum is satisfied, then the plan pays 100%.
- Generic: $40 copay
- Preferred brand: $80 copay
- Non-preferred brand: $120 copay
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.
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.
View the health care program comparison for a summary of these benefits
View the EPO plan FAQs
View Aetna's online directory for network providers
Log in to www.aetna.com if you are enrolled and want to view your claim status, history of claims, and more
Learn how NurseLine can help you treat symptoms at home and avoid unnecessary trips to the emergency room
View the Aetna Preventive Drug List for generic medications that are available at no cost to you (generic medications are displayed in lowercase italics)
View the Aetna Health Care Reform Preventive Drug List for all preventive medications that are available at no cost to you