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October 2023

There are upcoming changes to your plan’s drug

coverage — and we want to be sure you’re ready

Starting October 1, 2023 you’ll see changes to the drugs your Advanced Control Plan-Aetna covers. It’s

important that you review the changes in the chart enclosed. Talk to your doctor about how these

changes might impact you.

Find out how to keep your costs low

If the status of your current drug is changing, you may pay more for refilling them on or after

October 1, 2023. So, we want to make sure you understand your options and what to do next.

What to do if your drugs are changing

Talk to your doctor to find out if changing to a preferred drug is right for you. If they agree, have

them send a new prescription to your pharmacy so it’s ready for you to fill October 1, 2023.

Your doctor may decide it’s best for you to stay on your current drug. If so, they can ask for medical

exception. Or you can call us at the number on your member ID card to request one. If approved, you’ll

still pay your plan copay or cost-share, after you meet your plan’s deductible or out-of-pocket

requirements.

Need more support? We’re here to help.

• Visit the website listed on your member ID card to view your current plan details.

• Call us at the number on your member ID card.

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Changes beginning October 1, 2023

On or after this date, log in to your member website. Here, you can search for and estimate the cost of

your drug(s). You can also find options that may cost you less. Keep in mind, these costs will depend on

several things, like where you are with your deductible.

The changes listed in this chart are based on your plan information as of the date of this letter.

UPPER CASE = brand-name drug lower case = generic drug

Drug Name

Change(s)

BENLYSTA

Not covered under pharmacy benefit. May be covered under the

medical benefit

VYVANSE

Moving to non-preferred brand tier

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Health benefits and health insurance plans are offered, administered and/or underwritten by Aetna

Health Inc., Aetna Health Insurance Company of New York, Aetna Health Assurance 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. Pharmacy benefits are administered by an affiliated pharmacy benefit

manager, CVS Caremark. Aetna® is part of the CVS Health® family of companies.

Not all health services are covered. See plan documents for a complete description of benefits,

exclusions, limitations and conditions of coverage. To check coverage and copay information for a

specific medicine, log into your member website. For questions, please call the toll-free number on

the back of your member ID card.

Information is subject to change. In accordance with state law or insurer policies, changes to drug

coverage are not effective for commercial fully insured plans (including HMOs) in Louisiana, New

York, Texas, and in most circumstances Connecticut and Vermont, until the plans’ renewal date.

This document contains trademarks or registered trademarks of CVS Pharmacy, Inc. or one of its

affiliates; it may also contain references to products that are trademarks or registered trademarks of

entities not affiliated with CVS Health.

Policy forms issued in Oklahoma include: AL OK HCOC, HC OK HCOC.

Policy forms issued in Missouri include: AL HGrpPol 07, AL SG HGrpPol-1A 01, HI HGrpAg 05, HI

GrpAgAmend-2022 01, HO HGrpPol 04, HO GrpPolAmend-2022 01, HI SG HGrpAg-1A 01. AL IVL

HPOL-1A-2023-EPO-HIX 02, AL IVL SOB 1A EPO HIX 02R2, AL IVL HPOL-1A-2023-EPO 02, AL IVL

SOB 1A EPO 02R1.

Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat

people differently based on their race, color, national origin, sex, age, or disability.

Aetna provides free aids/services to people with disabilities and to people who need language

assistance.

If you need a qualified interpreter, written information in other formats, translation or other services,

call the number on your ID card.

If you believe we have failed to provide these services or otherwise discriminated based on a

protected class noted above, you can also file a grievance with the Civil Rights Coordinator by

contacting:

Civil Rights Coordinator,

P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779),

1-800-648-7817, TTY: 711,

Fax: 859-425-3379 (CA HMO customers: 860-262-7705), [email protected]

You can also file a civil rights complaint with the U.S. Department

of Health and Human Services,

Office for Civil Rights Complaint Portal,

available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or

at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F,

HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).

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, Coventry Health Care plans and

their affiliates (Aetna).

TTY:711

English

To access language services at no cost to you, call the number on your ID card.

      

 

Albanian

Për shërbime përkthimi falas për ju, telefononi në numrin që gjendet në kartën tuaj

të identitetit.

Amharic

የ ቋን ቋ አ ገ ልግሎቶችን ያ ለ ክፍያ ለ ማግኘት፣ በ መታወቂያ ዎት ላይ ያ ለ ውን ቁጥር ይደውሉ 

Arabic



Armenian

Ձեր նախընտրած լեզվով ավվճար խորհրդատվություն ստանալու համար

զանգահարեք ձեր բժշկական ապահովագրության քարտի վրա նշված

հէրախոսահամարով

Bantu-Kirundi

Kugira uronke serivisi z'indimi ata kiguzi, hamagara inomero iri ku karangamuntu

kawe

Bengali

           ।

Burmese

သင့္အေနျဖင့္ အခေၾကးေငြ မေပးရပဲ ဘာသာစကား၀န္ေဆာင္မႈမ်ား ရရွိႏုိင္ရန္၊ သင့္ ID

ကတ္ေပၚတြင္ရွိေသာ ဖုန္းနံပတ္အား ေခၚဆိုပါ။

Catalan

Per accedir a serveis lingüístics sense cap cost per a vostè, telefoni al número



Cebuano

Aron maakses ang mga serbisyo sa lengguwahe nga wala kay bayran, tawagi ang

numero nga anaa sa imong kard sa ID.

Chamorro

Para un hago' i setbision lengguåhi ni dibåtde para hågu, ågang i numiru gi iyo-mu

kard aidentifikasion.

Cherokee

ᏩᎩᏍᏗ ᎦᏬᏂᎯᏍᏗ ᎢᏅᎾᏓᏛᏁᏗ Ꮭ ᎪᎱᏍᏗ ᏗᏣᎬᏩᎳᏁᏗ ᏱᎩ, ᏫᎨᎯᏏᎳᏛᏏ ᎾᏍᎩ ᏗᏎᏍᏗ

ᏥᏕᎪᏪᎵ ᎤᎾᎢ ID ᏆᏂᏲᏍᏗ ᏣᏤᎵᎢ.

Chinese Traditional

如欲使用免費語言服務，請撥打您健康保險卡上所列的電話號碼

Choctaw

Anumpa tosholi i toksvli ya peh pilla ho ish i payahinla kvt chi holisso kallo iskitini

holhtena takanli ma i payah

Chuukese

Ren omw kopwe angei aninisin eman chon awewei (ese kamé), kopwe kééri ewe

nampa mei mak won noum ena katen ID

Cushitic-Oromo

Tajaajiiloota afaanii gatii bilisaa ati argaachuuf,lakkoofsa fuula waraaqaa

eenyummaa (ID) kee irraa jiruun bilbili.

Dutch

Voor gratis taaldiensten, bel het nummer op uw ziekteverzekeringskaart.

French

Pour accéder gratuitement aux services linguistiques, veuillez composer le numéro

indiqué sur votre carte d'assurance santé.

French Creole

(Haitian)

Pou ou jwenn sèvis gratis nan lang ou, rele nimewo telefòn ki sou kat idantifikasyon

asirans sante ou.

German

Um auf den für Sie kostenlosen Sprachservice auf Deutsch zuzugreifen, rufen Sie die

Nummer auf Ihrer ID-Karte an.

Greek





Gujarati

         ,    

    .

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



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 

               

    

Hawaiian





Hindi

          ,      

  

Hmong

Yuav kom tau kev pab txhais lus tsis muaj nqi them rau koj, hu tus naj npawb ntawm

koj daim npav ID.

Igbo





Ilocano

Tapno maakses dagiti serbisio ti pagsasao nga awanan ti bayadna, awagan ti

numero nga adda ayan ti ID kardmo.

Indonesian

Untuk mengakses layanan bahasa tanpa dikenakan biaya, silakan hubungi nomor

telepon di kartu asuransi Anda.

Italian

Per accedere ai servizi linguistici senza alcun costo per lei, chiami il numero sulla

tessera identificativa.

Japanese

無料の言語サービスは、 IDカードにある番号にお電話ください。

Karen

vXw>urRM>usdmw>rRpXRtw>zH;w>rRwz.

vXwtd.'D;tyShRvXeub.[h.tDRt*D><ud;b.vDwJpdeD.*H>vXttd.vXecd.*DR A(ID) tvdRM.wuh>I

Korean

무료 다국어 서비스를 이용하려면 보험 ID 카드에 수록된 번호로 전화해

주십시오.

Kru-Bassa

I nyuu kosna mahola ni language services ngui nsaa wogui wo, sebel i nsinga i ye

ntilga i kat yong matibla

Kurdish

ID



Lao

ţŊ

ţĻ

ŘţŃ

Ľņ

ໍ

ĺŘŅŊŘőŘń

ໍ

ţőŀļ

Ř, ŦŒ

ťńŒŘţņ

ťńō

ŦŅņ

ŁŇŖľ

ໍ

Řł

ŐĻœĽń

ŘŅ.

Marathi

  



   ,  ID 

  .

Marshallese













Micronesian-

Ponapean

Pwehn alehdi sawas en lokaia kan ni sohte pweipwei, koahlih nempe nan amhw

doaropwe en ID.

Mon-Khmer,

Cambodian



    

Navajo

Nepali

  



 







     





 



Nilotic-Dinka

 



Norwegian

For tilgang til kostnadsfri språktjenester, ring nummeret på ID-kortet ditt.

Pennsylvanian-

Dutch

Um Schprooch Services zu griege mitaus Koscht, ruff die Nummer uff dei ID Kaart.

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   

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  

    

    



            

Persian Farsi



Polish



podany na karcie identyfikacyjnej.

Portuguese

Para aceder aos serviços linguísticos gratuitamente, ligue para o número indicado

no seu cartão de identificação.

Punjabi

            ,   

     '  

Romanian



Russian





Samoan

o 'au'aunaga tau gagana e aunoa ma se totogi, vala'au le numera i

luga o lau pepa ID.

Serbo-Croatian



kartici.

Spanish

Para acceder a los servicios lingüísticos sin costo alguno, llame al número que figura

en su tarjeta de identificación.

Sudanic Fulfulde





Swahili

Kupata huduma za lugha bila malipo kwako, piga nambari iliyo kwenye kadi yako ya

kitambulisho.

Syriac-Assyrian



































































































































































Tagalog

Upang ma-access ang mga serbisyo sa wika nang walang bayad, tawagan ang

numero sa iyong ID card.

Telugu

     ,       

.

Thai

    

Tongan





Turkish



Ukrainian





Urdu





 ID 



Vietnamese





Yiddish

צאב ווקמע ןשארפ ךסרעוויסערפ סיופ י ןפאאצד טפור ,לנ םעומוא רעי ףאיי רעID ראקט .ל

Yoruba

























