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2021 Aetna California Four Tier Open Small Group ACA Plan

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2021 Aetna California Four Tier Open Small Group ACA Plan 2020 Aetna Pharmacy Drug Guide Aetna Small Group ACA Formulary - California Visit www.aetna.com/formulary for the most up-to-date information. For a summary of your coverage or benefits plan log in to your secure member site. Or call the toll-free number on your member ID card. The formulary is updated the first week of each month. The formulary is subject to change. Previous versions are no longer in effect. The Medical plan names to which this document applies to in the state of California are listed below: Plan Name Aetna Value Network HMO AWH Sharp OA Managed Choice® POS Aetna Value Network HMO HDHP AWH Sharp OA Managed Choice® POS HDHP AHF OA Managed Choice® POS AWH Southern California HMO AHF Savings Plus OA Managed Choice® POS HMO AWH MemorialCare OA Elect Choice® EPO HMO Basic AWH MemorialCare OA Managed Choice® POS HMO Basic HDHP AWH MemorialCare OA Managed Choice® POS HDHP HMO Deductible AWH PrimeCare HMO HMO Deductible HDHP AWH PrimeCare OA Elect Choice® EPO HMO HDHP AWH PrimeCare OA Managed Choice® POS OA Managed Choice POS AWH PrimeCare OA Managed Choice® POS HDHP OA Managed Choice POS HDHP AWH Providence OA Elect Choice® EPO Open Choice PPO AWH Providence OA Managed Choice® POS Open Choice PPO HDHP AWH Providence OA Managed Choice® POS HDHP Savings Plus OA Managed Choice® POS AWH Sharp OA Elect Choice® EPO Savings Plus OA Managed Choice® POS HDHP Health benefits and health insurance plans are offered, administered and/or underwritten by Aetna Health Inc., Aetna Health Insurance Company of New York, Aetna HealthAssurance Pennsylvania Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health Inc. and/or Aetna Life Insurance Company. In Utah and Wyoming by Aetna Health of Utah Inc. and Aetna Life Insurance Company. In Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole financial responsibility for its own products. 2021 Small Group ACA CA Table of Contents INFORMATIONAL SECTION..................................................................................................................4 ALTERNATIVE MEDICINES.................................................................................................................17 ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION.................................................17 ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS....................................................................32 ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER.......................................................... 54 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES..................................................................... 67 CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS...........67 CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS............90 ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND REGULATE HORMONES........................................................................................................................................... 130 GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS.......175 GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS...189 HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERS......................................................... 194 IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM.....202 MEDICAL DEVICES.............................................................................................................................. 213 NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS............................................240 OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS................................................................251 OTHER.....................................................................................................................................................259 PHARMACEUTICAL ADJUVANTS.................................................................................................... 259 RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS................................................. 259 TOPICAL - DRUGS TO TREAT EAR AND SKIN CONDITIONS.....................................................276 TOC-3 Definitions Brand name drug means a drug that is marketed under Generic drug means a drug that is the same as its brand a proprietary, trademark-protected name. A brand name name drug equivalent in dosage, strength, effect, how it drug is listed in this formulary in all CAPITAL letters. is taken, quality, safety, and intended use. A generic drug is listed in this formulary in italicized lowercase letters. Coinsurance means a percentage of the cost of a covered health care benefit that you pay after you have Medically Necessary means health care benefits paid the deductible, if a deductible applies to the health needed to diagnose, treat, or prevent a medical condition care benefit. or its symptoms and that meet accepted standards of medicine. Health insurance usually does not cover health Copayment means a fixed dollar amount that you care benefits that are not medically necessary. pay for a covered health care benefit after you have paid the deductible, if a deductible applies to the Non-formulary drug means a prescription drug that is health care benefit. not listed on this formulary. Deductible means the amount you pay for covered Out-of-pocket costs means your expenses for health health care benefits that are subject to the deductible care benefits that aren’t reimbursed by your health before your health insurer begins to pay. If your health insurance. Out-of-pocket costs include deductibles, insurance policy has a deductible, it may have either one copayments, and coinsurance for covered health care deductible or separate deductibles for medical benefits benefits, plus all costs for health care benefits that are and prescription drug benefits. After you pay your not covered. deductible, you usually pay only a copayment or Prescribing provider means a health care provider who coinsurance for covered health care benefits. Your can write a prescription for a drug to diagnose, treat, or insurance company pays the rest. prevent a medical condition. Drug Tier means a group of prescription drugs that Prescription means an oral, written, or electronic order correspond to a specified cost sharing tier in your from a prescribing provider authorizing a prescription health insurance policy. The drug tier in which a drug to be provided to a specific individual. prescription drug is placed determines your portion of the cost for the drug. Prescription drug means a drug that by law requires a prescription. Enrollee is a person enrolled in a health plan who is entitled to receive services from the plan. Prior Authorization means a decision by your health insurer that a health care benefit is medically necessary Exception request means a request for coverage of for you. If a prescription drug is subject to prior a non-formulary drug. If you, your designee, or your authorization in this formulary, your prescribing provider prescribing health care provider submits a request for must request approval from your health insurer to cover coverage of a non-formulary drug, your insurer must the drug before you fill your prescription. Your health cover the non-formulary drug when it is medically insurer must grant a prior authorization request when necessary for you to take the drug. it is medically necessary for you to take the drug. Exigent circumstances means when you are suffering Step therapy means a specific sequence in which from a medical condition that may seriously jeopardize prescription drugs for a particular medical condition your life, health, or ability to regain maximum function, or must be tried. If a drug is subject to step therapy in this when you are undergoing a current course of treatment formulary, you may have to try one or more other drugs using a non-formulary drug. before your health insurance policy will cover that drug Formulary or prescription drug list means the list of for your medical condition. If your prescribing provider drugs that is covered by your health insurance policy submits a request for an exception to the step therapy under the prescription drug benefit of the policy. requirement, your health insurer must grant the request when it is medically necessary for you to take the drug. Subscriber means the person who is responsible for payment to a plan or whose employment or other status, except for family dependency, is the basis for eligibility for membership in the plan. 1 How to use this guide Your guide includes a list of commonly used drugs covered on your pharmacy plan. The amount you pay depends on the drug your doctor prescribes. It’s either a flat fee or a percentage of the prescription’s price after you meet your deductible, if applicable. Preferred generic drugs cost less. Preferred brand drugs will have a higher cost. Refer to the Summary of Benefits for differences and information about the prescription drugs covered under your Outpatient prescription drugs and medical benefit in your plan. A prescription drug may be located by looking up Your plan includes the therapeutic category and class to which the drug • Brand and generic drugs that are hand-picked for their belongs or the brand or generic name of the drug quality and effectiveness in the alphabetical index; and • A specialty pharmacy fills specialty drug prescriptions If a generic equivalent for a brand name drug is not (ones that are injected, infused
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