Pharmacy

Formulary drug list

The formulary is a list of drugs chosen by Aetna Better Health of Kentucky and a team of doctors and pharmacists. Drugs on this list are generally covered under the plan as long as they are medically necessary. Members must fill their prescriptions at an Aetna Better Health of Kentucky network pharmacy and follow other plan rules.

Effective January 1, 2021, for Medicaid members, the list of covered drugs is the Single Preferred Drug List (PDL) from the Kentucky Department of Medicaid Services (DMS). Drugs designated as non-preferred on the PDL remain available to you when determined to be medically necessary through the prior authorization process. To see any Quantity Level Limits (QLL), please check the QLL Document. For additional information, please click here to visit the Kentucky Department of Medicaid Services (DMS) website.

Aetna Better Health of Kentucky also covers drugs and products that are not on the Single Preferred Drug List. You can download the Supplemental Formulary. To view medications that are covered on the Supplemental Formulary, you can search for drugs using our Supplemental Formulary Search Tool. Searches can be performed by drug name or by drug class. The tool will provide formulary status, generic alternatives and if there are any clinical edits (Prior Authorization, Quantity Limits, Age Limits etc).

Please review the DMS Single PDL, DMS Quantity Limits Document, and/or Supplemental Formulary for restrictions or recommendations regarding prescription drugs before prescribing a medication to an Aetna Better Health of Kentucky member.

Drug Recall - Immediate Action Needed

No current drug recalls

Aetna Better Health of Kentucky also covers certain over-the-counter drugs if they are on our list. Some of these may have rules about how they can be covered. If the rules for that drug are met, we will cover the drug. Over-the-counter drugs must have a prescription for them to be covered at no cost to our members.

Kentucky Medicaid Single PDL Prior authorization criteria (effective 01.01.2021) and Aetna Guidelines (effective 01.01.2021) for pharmacy prior authorization for:

Aetna Better Health of Kentucky also covers certain over-the-counter drugs if they are on our list. Some of these may have rules about how they can be covered. If the rules for that drug are met, we will cover the drug. Over-the-counter drugs must have a prescription for them to be covered at no cost to our members.

Kentucky Medicaid Universal PA Form (effective 08.24.2020)

Aetna Universal Pharmacy Prior Authorization 

 

To search press "CTRL + F" and type in the name you are looking for

Botulinum Toxins  

Cystic Fibrosis  

Daraprim (Pyrimethamine)  Updated 08.18.2020  

Egrifta 

Gonadotropin Releasing Hormone Analogs  

Hemophilia  Updated 08.18.2020

Idiopathic Pulmonary Fibrosis 

Increlex  

Interferons 

Interleukin-5 Antagonists  

Janus Associated Kinase Inhibitors  

To search press "CTRL + F" and type in the name you are looking for

Kentucky Medicaid Universal PA Form (effective 08.24.2020)

Aetna Universal Pharmacy Prior Authorization  

 

SGLT2 Inhibitors

Somatostatin Analogs  

Synagis  

Universal General Pharmacy 

Viscosupplements

 

We are committed to making sure our providers receive the best possible information, and the latest technology and tools available.

We have partnered with CoverMyMeds® and SureScripts to provide you a new way to request a pharmacy prior authorization through the implementation of Electronic Prior Authorization (ePA) program.

With Electronic Prior Authorization (ePA), you can look forward to:

  • Time saving
    • Decreasing paperwork, phone calls and faxes for requests for prior authorization
  • Quicker Determinations
    • Reduces average wait times, resolution often within minutes
  • Accommodating & Secure
    • HIPAA compliant via electronically submitted requests

No cost required! Let us help get you started!

Getting started is easy. Choose ways to enroll:

Billing Information: 

BIN: 610591

PCN: ADV

Group: RX8831

January 2021

  • No updates

 

 

Aetna Better Health Specialty Drug Program is managed through CVS Health Specialty Pharmacy. The Specialty pharmacies fill prescriptions and ship drugs for complex medical conditions, including hepatitis C, multiple sclerosis, hemophilia, rheumatoid arthritis and most cancer drugs. Medications provided through CVS specialty pharmacy include injectable, oral and inhaled drugs.

The Specialty Drug Program provides care management services to your members, including:

  • 24 hours a day, seven days a week access to a pharmacist
  • Disease-specific education and counseling by the CareTeamTM. The CareTeamTM are clinical professionals who review dosing and medication schedules, identify injection issues, provide education of potential side effects and provide information to help your patient to manage their medical condition.
  • Care coordination
  • Delivery of Specialty drugs to your patient’s home and/or your office in temperature-controlled packaging with the required supplies, i.e. needles, syringes, and alcohol wipes or patients can be directed to drop off and pick up most of their prescriptions at any CVS Pharmacy location (including those inside Target stores*)

Contact CVS Specialty Pharmacy at 1-800-237-2767 from 7:30 a.m. (EST) to 9:00 p.m. (EST) time, Monday – Friday. CVS Specialty Pharmacy will assist you in filling your patient’s specialty drug. Prior Authorization (PA) still applies to specific specialty drugs. You can check our health plan website to confirm PA requirements on the medications listed below.

Specialty medications can be delivered to the provider’s office, member’s home, or other location as requested.

Additional Pharmacies in the specialty network:

CVS Specialty Fax 1-800-323-2445

BioPlus Fax: 1-800-269-5493

Diplomat Specialty Infusion Group Fax 1-513-792-3838

Elwyn Specialty Pharmacy Fax: 1-610-545-6030

Nufactor Inc Fax 1-855-270-7347

OptumRx of Indiana (BriovaRX) Fax: 1-877-342-4596

OptumRx of Tennessee (BriovaRX) Fax: 1-888-791-7666

Pharmascript Fax: 1-773-961-8907

ProCare Pharmacy Direct, L.L.C. Fax: 1-412-825-8686

SenderraRx Fax: 1-888-777-5645

SimplicityRx Fax: 1-513-860-2436

St. Matthews Specialty Pharmacy Fax: 1-844-524-4673

University of Kentucky Specialty Pharmacy Fax: 1-859-323-1056

 

The step therapy program requires that you prescribe certain first-line drugs, either generic drugs or formulary brand drugs, before you can prescribe specific, second-line drugs. The formulary identifies drugs with these guidelines as “STEP.” See the link below.

Supplemental Step Therapy Guidelines

In addition, certain drugs on the formulary have quantity limits. The formulary flags these drugs with the letters “QLL” The QLLs are established based on FDA-approved dosing levels and nationally- established, recognized guidelines pertaining to the treatment and management of the condition being treated.

To request an override for the step therapy and/or quantity limit, please fax the correct pharmacy Prior Authorization request form to 1-855-799-2550. You can include any medical records that will support your request.