Member Pharmacy Benefits

MDHSS PDL

Medications covered on the Michigan Department of Health and Human Services (MDHSS) Single Preferred Drug List (PDL) can be found here

MDHSS Common Formulary

Medications covered on the MDHSS Common Formulary can be found here

Formulary Alternatives

For a list of PDL alternatives click here

The preferred Glucose meters and Test Strips are J&J One Touch products. The preferred pen needles are BD.

Pharmacy Billing Information 

Aetna Better Health of MI members may use the following information along with the ID number to process prescriptions at network pharmacies:

  • BIN: 610591
  • PCN: ADV
  • GROUP: RX8826

Pharmacy providers may go to CVS/Caremark for payer sheets and additional network or processing information.

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.

A formulary is a list of drugs that Aetna Better Health covers and the formulary consists of the MDHSS PDL and Common Formulary. To find out it if a drug that you take is covered, you can check the MDHSS PDL and Common Formulary for the most current coverage status.  Aetna Better Health also covers diabetic supplies. The preferred Glucose meters and Test Strips are J&J One Touch products. The preferred pen needles are BD.

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, via fax 1-855-799-2551, or through CoverMyMeds.com

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.

Updates to the PDL/Common Formulary can be found online using the formulary documents linked below:

MDHSS carves out specific classes of drugs. These drugs are covered by MDHSS Fee-or-service (FFS) using the Magellan Pharmacy Benefit Manager

For more information about MDHSS Fee-for-service carve outs please click here.

For confirmation of carved out agents use the FFS drug search tool

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 MDHSS 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.

If a drug is not listed on the formulary, a Pharmacy Prior Authorization Request form must be completed. Your doctor will have to 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, via fax 1-855-799-2551, or through CoverMyMeds.com.

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 the MDHSS PDL and Common Formulary.

Your doctor can request an override step therapy and/or a quantity limit by telephone at 1-866-316-3784, via fax 1-855-799-2551, or through CoverMyMeds.com

Aetna Better Health Specialty Drugs are filled by CVS Health Specialty Pharmacy. A Specialty pharmacy fills drugs but has other services to help you. The Specialty Drug Program has special services for you:

  • You can talk to a Pharmacist 24 hours a day, seven days a week
  • Disease-specific education and counseling are available by CVS
  • Care Coordination for you and your doctor
  • Delivery of Specialty drugs to your home and/or your doctor’s office is available for drop off and pick up at any CVS Pharmacy location (including those inside Target stores*)

You can contact CVS Specialty Pharmacy at 1-800-237-2767; TTY/TDD: 1-800-863-5488 from 7:30 a.m. (EST) to 9:00 p.m. (EST) time, Monday – Friday. CVS Specialty Pharmacy will assist you in filling your specialty drug. The specialty drug list is available here.

Frequently Asked Questions

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
  • 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 94467PALATINE

IL 60094-4467