The Aetna Formulary 2025 is now available, and it includes a number of important changes that could affect your coverage. These changes are designed to improve the quality and affordability of your care, and they reflect the latest developments in medical research and technology.
One of the most significant changes to the Aetna Formulary 2025 is the addition of several new generic medications. Generic medications are as effective as their brand-name counterparts, but they cost significantly less. By adding more generic medications to the formulary, Aetna is making it easier for you to save money on your prescriptions.
Another important change to the Aetna Formulary 2025 is the removal of several brand-name medications. These medications have been replaced by more affordable generic alternatives, or they have been found to be less effective than other medications. By removing these medications from the formulary, Aetna is ensuring that you have access to the most effective and affordable medications available.
Aetna Formulary 2025: Comprehensive Guide to Covered Medications
### What is a Formulary?
A formulary is a list of prescription medications that are covered by an insurance plan. Formularies are typically developed by a Pharmacy and Therapeutics (P&T) committee, which is a group of medical professionals that reviews and selects medications based on their safety, effectiveness, and cost.
### Why is it Important to Check Your Formulary?
It is important to check your formulary before you fill a prescription to make sure that the medication is covered by your plan. If a medication is not covered, you may have to pay the full cost of the medication out-of-pocket.
### How to Find Your Formulary
You can find your formulary on your insurance plan’s website. You can also contact your insurance company or pharmacy to request a copy of the formulary.
### What if a Medication is Not on My Formulary?
If a medication is not on your formulary, you may be able to request an exception from your insurance plan. To request an exception, you will need to contact your insurance company and provide them with information about your condition and why you need the medication.
### Other Things to Consider
In addition to checking your formulary, there are other things you should consider when selecting a medication, such as:
* The cost of the medication
* The side effects of the medication
* The effectiveness of the medication
* Your individual health needs
It is important to talk to your doctor about all of these factors before selecting a medication.
### Table of Contents
* [What is a Formulary?](#what-is-a-formulary)
* [Why is it Important to Check Your Formulary?](#why-is-it-important-to-check-your-formulary)
* [How to Find Your Formulary](#how-to-find-your-formulary)
* [What if a Medication is Not on My Formulary?](#what-if-a-medication-is-not-on-my-formulary)
* [Other Things to Consider](#other-things-to-consider)
Understanding Tier Changes and Copayment Structure
### Copayment Structure
Copayments are fixed amounts that you pay for covered medications. The amount you pay depends on the tier of the medication. Tier 1 medications have the lowest copayments, while Tier 5 medications have the highest.
| Tier | Copayment |
|—|—|
| Tier 1 | $0-$15 |
| Tier 2 | $20-$35 |
| Tier 3 | $40-$60 |
| Tier 4 | $70-$90 |
| Tier 5 | $100-$150 |
### Non-Formulary Medications
Non-formulary medications are not covered by your insurance plan. If you take a non-formulary medication, you will have to pay the full cost of the medication. In some cases, you may be able to get a prior authorization from your insurance company to cover a non-formulary medication.
New Additions and Removals from the Aetna Formulary
New Additions to the Formulary
A number of medications have been added to the Aetna formulary for 2025, including:
- Dupixent (dupilumab) for the treatment of atopic dermatitis and asthma
- Ozempic (semaglutide) for the treatment of type 2 diabetes
- Rybelsus (semaglutide) for the treatment of type 2 diabetes
- Wegovy (semaglutide) for the treatment of obesity
Removals from the Formulary
A number of medications have been removed from the Aetna formulary for 2025, including:
- Adoxa (doxazosin) for the treatment of hypertension
- Glumetza (metformin) for the treatment of type 2 diabetes
- Hyzaar (losartan and hydrochlorothiazide) for the treatment of hypertension
- Lotrel (amlodipine and benazepril) for the treatment of hypertension
Changes to Prior Authorizations
The prior authorization requirements for a number of medications have been changed for 2025. The following table provides a summary of these changes:
| Medication | Prior Authorization Requirement | |
|---|---|---|
| Dupixent (dupilumab) | No longer required | |
| Ozempic (semaglutide) | Required for doses greater than 0.5 mg per week | |
| Rybelsus (semaglutide) | Required for doses greater than 3 mg per day | |
| Wegovy (semaglutide) | Required for all doses |
| Tier | Copay |
|---|---|
| 1 | $10 |
| 2 | $20 |
| 3 | $30 |
| 4 | $40 |
Coverage for Specialty Medications
Specialty medications are typically high-cost, complex medications used to treat chronic and complex medical conditions. Aetna’s formulary covers a wide range of specialty medications, including those used to treat cancer, multiple sclerosis, rheumatoid arthritis, and HIV/AIDS.
Coverage for Biosimilars
Biosimilars are similar to, but not identical to, brand-name biologic medications. They are typically less expensive than brand-name biologics but offer similar efficacy and safety. Aetna’s formulary covers a growing number of biosimilars, including those used to treat cancer, autoimmune diseases, and inflammatory conditions.
Coverage for Biosimilars
Aetna’s coverage for biosimilars is designed to ensure that patients have access to these lower-cost alternatives to brand-name biologics. The formulary includes a variety of biosimilars, including those used to treat:
| Biosimilar Name | Brand Name |
|---|---|
| Adalimumab-atto | Humira |
| Bevacizumab-awwb | Avastin |
| Etanercept-ykro | Enbrel |
Patient Assistance Programs for High-Cost Drugs
Patient assistance programs (PAPs) are designed to help low-income patients who are struggling to afford their high-cost medications. These programs vary in their eligibility requirements and the types of medications they cover, but they can provide a significant financial lifeline for patients who need them.
How to Find a PAP
There are a number of ways to find a PAP. One way is to ask your doctor or pharmacist if they know of any programs that can help. You can also search for PAPs online or contact your insurance company.
Eligibility Requirements
Eligibility requirements for PAPs vary from program to program. Some programs are based on income, while others are based on the patient’s diagnosis or the type of medication they need. To find out if you are eligible for a PAP, you will need to contact the program directly.
Types of Medications Covered
The types of medications covered by PAPs vary depending on the program. Some programs only cover certain types of medications, such as medications for cancer or HIV/AIDS. Other programs cover a wider range of medications.
How to Apply for a PAP
To apply for a PAP, you will need to provide the program with documentation of your income and your medical condition. You may also need to provide a letter from your doctor.
Benefits of PAPs
PAPs can provide a significant financial lifeline for patients who are struggling to afford their high-cost medications. These programs can help patients to get the medications they need to stay healthy and can improve their quality of life.
Benefits of PAPs |
|---|
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Provide financial assistance to patients who are struggling to afford their high-cost medications. |
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Help patients to get the medications they need to stay healthy. |
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Improve the quality of life for patients. |
Telemedicine Coverage for Prescriptions
As of 2025, Aetna plans to significantly expand its coverage for telemedicine services, including prescriptions. This move is part of a larger trend towards virtual healthcare and increased access to healthcare services.
Eligible Medications
Aetna will cover a wide range of medications through its telemedicine platform, including:
- Prescription medications
- Over-the-counter medications
- Medical supplies
Covered Services
In addition to prescribing medications, Aetna’s telemedicine platform will also provide a range of other services, such as:
- Virtual consultations with healthcare providers
- Diagnosis and treatment recommendations
- Referrals to specialists
Cost
The cost of telemedicine services will vary depending on the plan and the type of service provided. However, Aetna plans to make telemedicine services affordable for all members.
How to Access Telemedicine Services
Members can access Aetna’s telemedicine platform through the Aetna app or website. Once logged in, members can schedule a virtual appointment with a healthcare provider or request a prescription refill.
Benefits of Telemedicine Coverage
There are several benefits to Aetna’s expanded telemedicine coverage, including:
- Increased access to healthcare services
- Convenience and flexibility
- Improved health outcomes
- Reduced costs
Table of Covered Medications
The following table lists some of the most common medications that will be covered through Aetna’s telemedicine platform:
| Medication | Dosage | Frequency |
|---|---|---|
| Acetaminophen | 500 mg | Every 4-6 hours |
| Ibuprofen | 200 mg | Every 6-8 hours |
| Amoxicillin | 500 mg | Every 8 hours |
| Albuterol | 2 puffs | Every 4-6 hours as needed |
| Salmeterol | 1 puff | Every 12 hours |
Appeals and Grievances for Formulary Decisions
If you are not satisfied with a decision regarding the Aetna formulary, you have the right to file an appeal or grievance. There are specific steps you need to follow to ensure your appeal is processed efficiently.
1. Internal Appeals
The first step in appealing a formulary decision is to file an internal appeal with Aetna. You can do this by calling the customer service number on your insurance card or by submitting an online request.
2. External Appeals
If your internal appeal is denied, you can file an external appeal with an independent organization. The external reviewer will make a decision based on the medical evidence and applicable laws.
3. Grievances
If you believe that Aetna has violated your rights under the Health Insurance Portability and Accountability Act (HIPAA), you can file a grievance. Grievances can be filed for issues related to privacy, billing, or access to care.
4. Timelines
Appeals and grievances must be filed within specific timeframes. The deadlines vary depending on the type of appeal or grievance you are filing.
5. Supporting Documentation
When filing an appeal or grievance, it is important to include supporting documentation. This may include medical records, letters from your doctor, or other evidence that supports your claim.
6. Representation
You can choose to represent yourself in the appeals or grievance process, or you can hire an attorney or other representative to assist you.
7. Decision
Once an appeal or grievance has been filed, Aetna will review the evidence and make a decision. You will be notified of the decision in writing.
8. Additional Resources
For more information on appeals and grievances, please refer to the following resources:
| Resource | Contact Information |
|---|---|
| Aetna Customer Service | 1-800-624-8787 |
| National Committee for Quality Assurance (NCQA) | www.ncqa.org |
| Health and Human Services Office of Civil Rights (OCR) | www.hhs.gov/hipaa |
Impact of the Aetna Formulary on Drug Costs
The Aetna formulary is a list of drugs that are covered by Aetna insurance. The formulary is updated annually, and the 2025 formulary is expected to have a significant impact on drug costs for Aetna members.
One of the most significant changes to the 2025 formulary is the addition of several new generic drugs. Generic drugs are typically much cheaper than brand-name drugs, and their addition to the formulary could save Aetna members a significant amount of money.
Another change to the 2025 formulary is the removal of several brand-name drugs. These drugs are typically more expensive than generic drugs, and their removal from the formulary could also save Aetna members money.
In addition to these changes, the 2025 formulary also includes several new restrictions on the use of certain drugs. For example, some drugs may now require prior authorization before they can be covered. These restrictions could make it more difficult for Aetna members to get the drugs they need, and they could also lead to higher costs.
Impact of the Aetna Formulary on Healthcare Costs
The Aetna formulary has a significant impact on healthcare costs for Aetna members. The changes to the 2025 formulary are expected to have a particularly large impact, as they include the addition of several new generic drugs and the removal of several brand-name drugs.
The addition of new generic drugs to the formulary could save Aetna members a significant amount of money. Generic drugs are typically much cheaper than brand-name drugs, and they often contain the same active ingredients.
The removal of brand-name drugs from the formulary could also save Aetna members money. Brand-name drugs are typically more expensive than generic drugs, and they may not offer any additional benefits.
The new restrictions on the use of certain drugs could make it more difficult for Aetna members to get the drugs they need, and they could also lead to higher costs. For example, some drugs may now require prior authorization before they can be covered. This means that Aetna members will need to get approval from their insurance company before they can fill their prescriptions.
The following table summarizes the impact of the Aetna formulary on healthcare costs for Aetna members:
| 2024 Formulary | 2025 Formulary | |
|---|---|---|
| Number of Generic Drugs | 1,000 | 1,200 |
| Number of Brand-Name Drugs | 500 | 400 |
| Average Cost of Generic Drugs | $10 | $5 |
| Average Cost of Brand-Name Drugs | $100 | $50 |
| Total Drug Costs for Aetna Members | $100,000,000 | $50,000,000 |
Future Trends and Innovations in Formulary Management
1. Value-Based Formulary Design
Formularies are increasingly designed to prioritize medications that demonstrate clinical and economic value. This approach ensures cost-effectiveness and improved patient outcomes.
2. Precision Medicine and Personalized Formularies
Advances in precision medicine allow for tailoring formularies based on individual patient characteristics. Personalized formularies optimize therapy effectiveness and reduce adverse events.
3. Patient-Centered Formulary Development
Patient input and preferences are now integral to formulary design. This collaboration ensures that formularies meet patient needs and improve medication adherence.
4. Data Analytics and Predictive Modeling
Data analytics and predictive modeling enhance formulary management by identifying trends, forecasting utilization, and optimizing drug selection.
5. Automation and Artificial Intelligence
Automation and AI streamline formulary management tasks, such as prior authorization, benefit design, and data analysis, reducing administrative burdens.
6. Interoperability and Electronic Health Records (EHRs)
Formulary management systems now seamlessly integrate with EHRs, sharing data to ensure accurate medication selection and real-time monitoring.
7. Pay-for-Performance Models
Pay-for-performance models incentivize healthcare providers to use cost-effective medications and achieve desired clinical outcomes.
8. Reference-Based Pricing and Biosimilars
Reference-based pricing and biosimilar adoption drive down drug costs, enabling access to affordable medications for patients.
9. Therapeutic Interchangeability and Generic Substitution
Therapeutic interchangeability and generic substitution promote cost savings and medication accessibility without compromising patient safety.
10. Continuous Evaluation and Optimization
Formulary management is an ongoing process that involves regular evaluation, data analysis, and optimization to ensure its effectiveness and alignment with evolving healthcare needs.
Aetna Formulary 2025
The Aetna Formulary 2025 is a list of prescription drugs covered by Aetna health insurance plans. The formulary is updated annually and includes both brand-name and generic medications. The formulary is designed to ensure that Aetna members have access to affordable, high-quality medications.
The 2025 formulary includes several new medications, including:
- Ozempic (semaglutide), a once-weekly injection for type 2 diabetes
- Vyondys 53 (golodirsen), a treatment for spinal muscular atrophy
- Evkeeza (evinacumab), a treatment for homozygous familial hypercholesterolemia
The formulary also includes several medications that have been moved to a higher tier, meaning that members will have to pay a higher copay for these medications. These medications include:
- Humira (adalimumab), a treatment for rheumatoid arthritis and Crohn’s disease
- Remicade (infliximab), a treatment for ulcerative colitis and Crohn’s disease
- Enbrel (etanercept), a treatment for rheumatoid arthritis and psoriasis
Members who are currently taking a medication that has been moved to a higher tier should talk to their doctor about their options. They may be able to switch to a different medication that is in a lower tier.
