Pharmacy Benefits

You now have the ability to search for drugs using our new 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), 

Note:  Effective 9/30/2016, Aetna Better Health of MI will be transitioning to Michigan's Commn Drug Formulary.  

Prescription drugs are often an important part of your health care. As an Aetna Better Health of Michigan member, you have the right to certain prescription drug benefits.

Aetna Better Health of Michigan covers prescription drugs and certain over – the – counter drugs when presented with a prescription at a pharmacy.

To find out it if a drug that you take is covered, you can check our formulary. A formulary is a list of drugs that Aetna Better Health covers. You can use the prescription drug search tool to find out if a drug is covered. You may also request a printed copy of this formulary by calling Member Services. If you have any questions about a drug that is not listed, please call Member Services toll-free at 1-866-316-3784 (TTY 711), 24 hours a day, 7 days a week.

If a drug is not listed on the formulary, a Pharmacy Prior Authorization Request form must be completed. Your doctor will complete this form. They must show why a formulary drug will not work for you. They must include any medical records needed for the request.

The Pharmacy Prior Authorization form is available on our website. Your doctor may make a request by telephone at 1-866-316-3784 or via fax 1-855-799-2551.

Aetna Better Health of Michigan Members must have their prescriptions filled at a in network pharmacy to have their prescriptions covered at no cost to them. You may go to our website to search for an in-network pharmacy near your zip code.

Prior authorization process:

Aetna Better Health of Michigan’s pharmacy prior authorization (PA) process is designed to approve drugs that are medically needed. We require doctors to obtain a PA before prescribing or giving out the following:

• Injectable drugs provided by a pharmacy
• Non-formulary drugs that are not excluded under a State’s Medicaid program
• Prescriptions that do not follow our guidelines (like quantity limits, age limits or step therapy)
• Brand name drugs, when a generic is available

Aetna Better Health of Michigan’s Medical Director decides if a drug is denied or approved using our guidelines. The Medical Director may need additional information before making a decision. This information may include the following:

• Drugs on the formulary have been tried and does not work (i.e., step therapy)
• No other drugs on the formulary would work as well as the drug requested
• The request is acceptable by the Federal Drug Administration (FDA) or is accepted by nationally noted experts
• For brand name drug requests, a completed FDA MedWatch form documenting failure or issues with the generic equal is required.

Both parties will be told of the decision through the telephone or mail.

Aetna Better Health of Michigan will fill prescriptions for a seventy-two (72) hour supply if the member is waiting for a decision by the Plan.

Step therapy and quantity limits:

The step therapy program requires certain drugs, such as generic drugs or formulary brand drugs to be prescribed before a specific second-line drugs is approved. Drugs having step therapy are listed on the formulary with “STEP”. Certain drugs on the Aetna Better Health of Michigan formulary have quantity limits and are listed on the formulary with “QLL”

The QLLs are based on FDA-approved doses and on nationally noted guidelines.

Your doctor can request an override step therapy and/or a quantity limit. They can fax a Pharmacy Prior Authorization Request form with medical records to 1-855-799-2551.

CVS Caremark Specialty Pharmacy:

Some drugs are considered Specialty drugs. They treat conditions, such as cancer, multiple sclerosis, and rheumatoid arthritis. Specialty drugs may not be available in your local pharmacy.  A prior authorization is needed before they can be filled and delivered. Your doctor can call 1-866-316-3784 to request prior authorization, or complete the prior authorization form found on our website at, www.aetnabetterheath.com/Michigan or fax to 1-855-799-2551.

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

Mail order prescriptions:

Aetna Better Health of Michigan offers mail order prescription services through CVS Caremark. Use one of the following to request this service:

• Call CVS Caremark, toll free at 1-800-552-8159/TTY 711, Monday to Friday between 8 a.m. and 8 p.m., for help to sign up for mail order service. CVS Caremark will call the prescribing provider to get the prescription with the member’s ok.

• Go online to: https://www.caremark.com/wps/portal/!ut/p/c4/04_SB8K8xLLM9MSSzPy8xBz9CP1An_z0zDz9gnRHRQDSauup/
• Log in and sign up for mail service online. If the member gives an ok, CVS Caremark will call the prescribing provider to get the prescription.
• By requesting your doctor to write a prescription for a 90-day supply with up to one year of refills. CVS Caremark will mail a mail service order form. When the member receives the form, the member fills it out and mails CVS Caremark the prescription and the order form. Forms should be mailed to:

 CVS CAREMARK

PO BOX 94467

               PALATINE, IL 60094-4467