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-329-2779 (1-866-FAX-ASRX) Today s Date: Anticipated Start Date: PATIENT INFORMATION First Name: Last Name: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: DOB: Height: Weight: Allergies: Ship Meds to: Home Work Doctor s Office INSURANCE INFORMATION Primary Insurance: Pharmacy Benefit Manager (PBM): Policy #: Group #: Insured: Phone: Medicare: Yes No If Yes, provide #: Medicaid: Yes No If Yes, provide #: Secondary Insurance: Policy #: Group #: Insured: Phone: PHYSICIAN INFORM.
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6ml FAQ
Note: Medications used for the sole purpose of weight reduction are generally not a covered benefit under most Aetna drug benefits plans. Coverage may be provided under the member's Aetna medical benefits plan. Please see plan benefit descriptions for further detail.
M EX = Medical Exception - This means the member or treating physician or health care professional must obtain a medical exception from Aetna, in order for the medication to be eligible for coverage. Medical Exception criteria apply to non-formulary drugs for members enrolled in or covered by closed benefits plans.
Exceptions requests are granted when a plan sponsor determines that a requested drug is medically necessary for an enrollee. Therefore, an enrollee's prescriber must submit a supporting statement to the plan sponsor supporting the request.
Definitions: Out-of-pocket (OOP) max: The highest amount you could pay in a given year for services (excludes premium). Copay/coinsurance: The amount you pay per visit or prescription to treat an injury or illness. It typically counts toward your OOP max.
After you meet your deductible, you pay a smaller portion of your medical costs. (This is your coinsurance.) Your plan pays the rest. Once you meet your out-of-pocket maximum (this is your deductible plus coinsurance limit), your plan pays for all covered medical services in full.
is currently listed on the Aetna Formulary Exclusions and Step-Therapy lists. * Therefore, it is excluded from coverage for members enrolled in prescription drug benefit plans that use a closed formulary or that require step-therapy criteria, unless a medical exception is granted.
All 2024 Aetna Medicare Eagle plans will feature a $0 monthly plan premium, $0 primary care copay (including walk-in clinics), dental, vision, hearing, OTC allowance and a SilverSneakers fitness benefit. These plans also offer $0 copays for labs, colonoscopies and routine eye and hearing exams.
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