Pharmacy Management Program FAQs for Health Care Providers

If the following terms and conditions are acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled “I agree”.

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  • The term precertification here means the utilization review process to determine if the requested service, procedure, prescription drug, or medical device meets the company’s clinical criteria for coverage. it does not mean precertification as defined by texas law as reliable representation of payment for care or services for fully insured hmo and ppo members.
  • Applies to: aetna choice® pos, aetna choice pos ii, aetna medicare℠ plan (ppo), aetna medicare plan (hmo), all aetna healthfund® products, aetna health network only℠, aetna health network option℠ , aetna open access® elect choice®, aetna open access hmo, aetna open access managed choice®, open access aetna select℠, elect choice, hmo, managed choice pos, open choice®, quality point-of-service® (qpos® ), and aetna select℠ benefit plans and all products that may include aexcel®, choose and save℠, aetna performance network or savings plus networks. not all plans are offered in all service areas.
  • all services deemed “never effective” are excluded from coverage. Aetna defines a service as “never effective” when it is not recognized in accordance with professional standards of safety and effectiveness in the United States for diagnosis, care, or treatment. visit the secure website, available through www.aetna.com, for more information. click on “claims”, “cpt/hcpcs coding tool”, “clinical policy code search”.
  • The five character codes included in the aetna precertification code lookup tool are derived from current procedural terminology (cpt®), copyright 2020 american medical association (ama). cpt is developed by the ama as a list of descriptive terms and five-character identification codes and modifiers for reporting medical services and procedures performed by physicians.
  • responsibility for the content of the aetna precertification code lookup tool rests with aetna and no endorsement by ama is intended or should be implied. la ama disclaims all liability for any consequence or liability attributable to or related to any use, non-use, or interpretation of the information contained in the aetna precertification code lookup tool. Fee schedules, basic unit values, relative value guides, conversion factors, or scales are not included anywhere in cpt. any use of cpt outside of aetna’s precertification code lookup tool should refer to most current procedural terminology which contains the most up-to-date and complete list of cpt codes and descriptive terms. applicable fars/dfars apply.
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    Current Procedural Terminology License, Fourth Edition (“cpt®”)

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    • cpt only copyright 2020 american medical association. All rights reserved. cpt is a registered trademark of the american medical association. you, your employees and agents are authorized to use cpt only as included in the aetna precertification code lookup tool solely for your personal use when directly participating in health care programs administered by aetna, inc. You acknowledge that ama owns all copyright, trademark and other rights in cpt. any unauthorized use herein is prohibited, including by way of illustration and not limitation, making copies of cpt for resale and/or license, transferring copies of cpt to any party not bound by this agreement, creating any derivative or modified work of cpt, or make any commercial use of cpt. license to sue cpt for any unauthorized use herein must be obtained from american medical association, cpt intellectual property services, 515 n. state street, chicago, illinois 60610. applications are available on the american medical association website, www.ama-assn.org/go/cpt.
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      united states government rights

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      • this product includes cpt, which are commercial technical data and/or computer databases and/or commercial computer software and/or commercial computer software documentation, as applicable, that were developed solely at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. USA. uu. the government’s rights to use, modify, reproduce, publish, perform, display or disclose these technical data and/or computer databases and/or computer software and/or computer software documentation are subject to copyright restrictions. limited by dfars 252.227-7015( b)(2) (June 1995) and/or subject to the restrictions of dfars 227.7202-1(a) (june 1995) and dfars 227.7202-3(a) (june 1995) , as appropriate for the us department of defense acquisitions and limited rights restrictions of 52.227-14 (June 1987) and/or subject to the restricted rights provisions of 52.227-14 (June 1987) and 52.227-19 (June 1987), depending on applicable, and any applicable agency for supplements, for non-department of defense federal acquisitions.
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        disclaimer of guarantees and responsibilities.

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        • cpt is provided “as is” without warranty of any kind, either express or implied, including, but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, base units, relative values, or related listings are not included in cpt. The American Medical Association (AMA) does not directly or indirectly practice medicine or provide medical services. Responsibility for the contents of this product rests with Aetna, Inc. and no endorsement by the owner is intended or implied. la ama disclaims any responsibility for any consequence or obligation attributable to or related to any use, non-use or interpretation of the information contained or not contained in this product.
        • This Agreement will terminate upon notice if you violate its terms. the housekeeper is a third party beneficiary of this agreement.
        • If the above terms and conditions are acceptable to you, please indicate your agreement and acceptance by selecting the “I agree” button.
        • The information contained on this website and the products described herein may not reflect product design or product availability in arizona. therefore, arizona residents, members, employers, and brokers should contact aetna directly or their employers for information about aetna products and services.
        • This information is not an offer of coverage or medical advice. it is only a partial overview of plan or program benefits and is not a contract. In the event of a conflict between your plan documents and this information, the plan documents will control.

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