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Pharmacy PA guidelines
Pharmacy PA guidelines
Medicaid guidelines and policies
Continuous glucose monitor (PDF)
Diabetic test strips quantity limit (PDF)
Medicaid step therapy criteria (PDF)
Medicare-Medicaid (Aetna Better Health® Premier Plan) guidelines and policies
Electronic PA (ePA)
Electronic PA (ePA)
You need the right tools and technology to help our members. That’s why we’ve partnered with CoverMyMeds® and Surescripts to provide a new way to request a pharmacy PA with our ePA program.
With ePA, you can look forward to saving time with:
- Less paperwork
- Fewer phone calls and faxes
- Quicker determinations
- Safe and secure HIPAA-compliant submitted requests
- Easy upload of clinical documents
Enroll now
Getting started with ePA is free and easy. You’ll need this info to enroll:
Medicaid:
BIN: 610591
GRP: RX8826
PCN: ADV
Medicare-Medicaid plan:
BIN: 610591
GRP: RX8827
PCN: MEDDADV
You can enroll two different ways:
Other ways to request PA
If you don’t want to enroll in ePA, you can request PA:
By phone
Call Provider Relations:
Medicaid: 1-866-316-3784 (TTY: 711)
Medicare-Medicaid plan: 1-855-676-5772 (TTY: 711)
By fax
Check “Request forms” in the next section to find the right form. Then, fax it with any supporting documentation for a medical necessity review to your plan’s fax number:
Medicaid fax: 866-602-1251
Medicare-Medicaid plan fax: 844-242-0914
Request forms
If you don’t see the right form in the list, you can use the uniform prescription drug PA form for your plan:
Otherwise, check for the drug class or drug name that matches your needs:
Step therapy preferred drug list (Medicare Part B) (PDF)
Abraxane (albumin-bound paclitaxel) Medicare (PDF)
Actemra (Tocilizumab) Medicare (PDF)
Avsola (infliximab-axxq) injectable Medicare (PDF)
Beovu (brolucizumab-dbll) injectable Medicare (PDF)
Botulinum toxins Medicare (PDF)
Cimzia (certolizumab pegol) Medicare (PDF)
Entyvio (vedolizumab) Medicare (PDF)
Erythropoesis stimulating agents (ESAs) medications/dialysis Medicare (PDF)
Evenity (romosozumab) Medicare (PDF)
Eylea (aflibercept) Medicare (PDF)
Pegfilgrastim (fulphila, neulasta, nyvepria, udenyca, and ziextenzo) Medicare (PDF)
Filgrastim (granix, neupogen, nivestym, zarxio) Medicare (PDF)
Herceptin (trastuzumab) Medicare (PDF)
Ilumya (tildrakizumab) Medicare (PDF)
Immune globulin (IG) therapy Medicare (PDF)
Inflectra (infliximab) Medicare (PDF)
Lemtrada (alemtuzumab) Medicare (PDF)
Leqvio (inclisiran) Medicare (PDF)
Lucentis (ranibizumab) Medicare (PDF)
Orencia (abatacept) Medicare (PDF)
Prolia, xgeva (denosumab) Medicare (PDF)
Pulmonary arterial hypertension (infusible, inhalation, or injectable medication) Medicare (PDF)
Remicade (infliximab) Medicare (PDF)
Renflexis (infliximab-abda) Medicare (PDF)
Rituxan (rituximab) Medicare (PDF)
Stelara (ustekinumab) Medicare (PDF)
Susvimo (ranibizumab) Medicare (PDF)
Tremfya (guselkumab) Medicare (PDF)
Tysabri (natalizumab) Medicare (PDF)
Vabysmo (faricimab-SVOA) Medicare (PDF)
Viscosupplementation medications Medicare (PDF)
