Do not give this form to your employer.
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Title: Jan19 HCR Preventive Drug List Subject: Jan19 HCR Preventive Drug List Created Date: 12/13/2018 8:28:27 AM AHFS Drug Information® with AHFSfirstReleases®. Unless otherwise required by law and if covered as indicated above, Aetna will cover contraceptives in accordance with the criteria below.Under some plans, including plans that use an open or closed formulary, If it is medically necessary for a member to be treated initially with a medication subject to step-therapy, the member, a person appointed to manage the member’s care, or the member's treating physician may contact the Aetna Pharmacy Management Precertification Unit to request coverage as a medical exception at Formulary Excluded contraceptives are excluded from coverage for members enrolled in a closed formulary unless a medical exception is obtained. Aetna will not disclose your election of coverage to your employer. Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna). That’s only six weeks (unless you have a qualifying life event or you live in a state with its own marketplace) to find a plan or change to a plan that better fits your needs. Q���r�.�H����C��Xgs~�1=��T�ܫ�3��X"P�a��a a����,b�&5 ���z��Fe�n�a��u{�Rf}�Jz�-�bi畢�U�Å՟bA��gk.fX�5����� ( Dysfunctional uterine bleeding (DUB) is characterized by abnormal uterine bleeding in pattern, frequency, regularity or quantity and can include:Hypermenorrhea: cycles regular and menses of normal duration, but blood loss excessive (>80mL per cycle)Menorrhagia: interval normal but duration and flow excessiveMetrorrhagia: interval irregular, duration and flow excessiveMenometrorrhagia: interval irregular, duration and flow excessive and intermenstrual bleedingHypomenorrhea: cycles regular, but blood loss abnormally decreasedHirsutism secondary to ovarian dysfunction (excessive hairiness)Polycystic ovary syndrome (many cysts on the ovary/cystic ovaries)Perimenopausal symptoms - hormone replacement for menopausePharmacy Benefit Plans with Contraceptive coverage:Pharmacy Benefit Plans without Contraceptive coverage:if determined that a preferred oral or non-oral contraceptive is not medically appropriate for a reason not included in criteria above
The SBC shows you how you and the plan 0 1 of 8 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019- 12/31/2019 Aetna: Essential PPO Plan Coverage for: All Coverage Tiers | Plan Type: PPO . January 18, 2019, admin, Leave a comment. Open Enrollment runs from November 1 and lasts through December 15. Aetna considers the Formulary Excluded, oral contraceptives to be medically necessary for members who meet ANY of the criteria listed below:Formulary Excluded contraceptives are Non-Preferred Brand contraceptives and have a higher copay for members enrolled in prescription drug benefit plans that use an open formulary. endstream endobj startxref About your drug list. Aetna considers Non-Preferred Brand oral contraceptives medically necessary for members who meet ANY of the following criteria listed below:Based on available clinical literature, contraceptives may be considered medically necessary for any of the following documented conditions:1. Return this form to: Aetna NY Contraceptive Coverage PO Box 14280 Lexington, KY 40512-4280 . aetna supplemental contraceptive ppo. 288 0 obj <>stream 225 0 obj <> endobj Continue.
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