Aetna does not automatically cover vaccination and prophylaxis for their members traveling to areas where malaria and typhoid are endemic.
I'm preparing to travel to tropica Lima, Argentina, and Paraguay. I was prescribed two anti-malarials (one for drug resistant malaria (Malarone), one cheaper version (chloroquine phosphate) for the areas where the paracite hasn't learned to fight off the cheap drug yet, and Vivotif Typhoid vaccine to prevent typhoid.
I was amazed to arrive at the pharmacy and see that Aetna had denied coverage for my vaccines and prophalactics. I called Aetna to learn why. Their logic: bizarre.
My favorite - chloroquine phosphate is only on their formulary as a treatment for malaria, and the minimum prescription is 30 pills, for a course of treatment after one contracts malaria. So, my pharmacy was willing to sell me six pills for $28.59, but Aetna would only buy in lots of 30, presumably for $142.95. So, they would be happy to pay the full amount and have me throw away 26 pills worth $114.36. That seems like a great idea.
Being literate, I actually read the instructions provided by my pharmacy for these drugs. Although Walgreens and my physician seem aware of this fact, Aetna apparently is unaware that one of the "Common Uses" of Chloroquine is, "to prevent and treat malaria."
The Malarone and Vivotif Typhoid vaccine they would be willing to pay for as prescribed, but my physician needed to call in first to get these drugs pre-certified.
By what stretch of the imagination are malaria and typhoid vaccines the types of drugs that require special (expensive) communication from my physician to the insurance company to receive special permission to cover? Obviously, none.
Aetna must hope that I will decide that it's not worth my extra time to call Aetna, then call my physician, have my physician call Aetna, have my physician write an appeal to be able to use these drugs in a way different than Aetna thinks they should be used, wait for a letter from the "medical director" of Aetna approving (or denying) the use, go back to the pharmacy, have the pharmacy refund my payment in excess of my copay, have the pharmacy resubmit their bills to Aetna, and hope that all the above happens in the right order.
They may be right. What a great business model. Collect my premium, and then keep the money they owe me.
God help those who are actually ill and need to deal with these bastards.