Pharmacy

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

MDHSS Opioid Resources

Click here for more information about the opioid resources provided by MDHSS  including a link to a copy of a Nonopioid Directive form in your language.

On October 1, 2020, The Michigan Department of Health and Human Services (MDHHS) implemented a Single Pharmacy Drug List (PDL). This change is because of a MDHHS policy change and effects all Michigan Medicaid Health Plans.

The PDL is a listing of drugs that are covered by Michigan Medicaid. There are two categories of coverage, preferred and non-preferred. The complete PDL can be found here

Not all covered drugs are listed on the PDL, MDHSS still covers drugs through the Michigan Medicaid Common Formulary. The common formulary may be found here.

Aetna Better Health also covers diabetic supplies. The preferred glucose meters and test strips are Lifescan OneTouch® products. The preferred lancets and lancing devices are Lifescan OneTouch Delica® and Delica® Plus. The preferred pen needles are Becton Dickinson (BD) products. As of 9/1/2022, The preferred continuous glucose monitors (CGMs) are Dexcom G6 and Freestyle Libre (both require prior authorization).

Please review the formulary for any restrictions or recommendations regarding prescription drugs before prescribing a medication to an Aetna Better Health of Michigan patient. Drugs that are not covered on the PDL or are listed as non-formulary will require a prior authorization. MDHSS has a list of PDL criteria that can be found here. Drugs that are listed under the common formulary have criteria listed here.

 

MDHSS carves out specific classes of drugs. These drugs are covered by MDHSS Fee-for-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.

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

If your members take medicine for an ongoing health condition, they can have their medicines mailed to their home. Aetna Better Health works with a company called CVS Health to provide this service, at no cost to our members.

If they choose this option, their medicine comes right to their door. There are other benefits to home delivery:

  • Pharmacists check each order for safety.
  • Members can order refills by mail, by phone, online, or they can sign up for automatic refills.
  • Members can talk with pharmacists by phone at any time 24 hours a day, 7 days a week.

 Members can sign up for this service in one of three ways. They can:

  • Call CVS Health toll-free at 1-800-552-8159 Monday to Friday between 8 a.m. and 8 p.m.,. CVS representatives will help your member sign up for home delivery. (As you are the provider, CVS will call you to get the prescription.)
  • Go online. Then, log in and sign up for ReadyFill. Again, CVS Health will contact you, the provider, to get a prescription.
  • Request a prescription from you for a 90-day supply with up to one year of refills. The member will then complete the mail- order services form and mail it to CVS Health along with the prescription.

CVS Health Mail Order Service Form English / Spanish

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

Aetna Better Health 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.

Requests for Medications requiring Prior Authorization (PA) will be reviewed based on the PA Guidelines for that medication.

Prior Authorization guidelines can be found below.

 

To obtain a Prior Authorization for a medication, doctors can call Aetna Better Health of Michigan at 1-866-316-3784 or utilize our electronic prior authorization request process. 

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
    •  Getting started is easy. Choose ways to enroll:
    • No cost required! Let us help get you started!
  • BIN: 610591
  • PCN: ADV
  • GROUP: RX8826
  • If not utilizing ePA, call us at 1-866-316-3784 Providers select * then say "Authorization" then "Submit One" then "Pharmacy" to submit a medication prior authorization.
  • Or you can fax an authorization form designed specifically for pharmacy requests. Doctors can download the forms and fax the request to 1-855-799-2551. Please include any supporting medical records that will assist with the review of the prior authorization request.
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  • Aetna Better Health of Michigan Pharmacy Prior Authorization Phone number: 1-866-316-3784
  • Pharmacy Prior Authorization Fax numbers: 1-855-799-2551

 

CVS Caremark Pharmacy Help Desk:  1-855-432-6843

Authorization forms

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, multiple sclerosis, 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.

 

 

 

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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.”  Aetna Better Health of Michigan follows the Michigan State Medicaid Step Therapy Criteria, when available, located here

When state criteria does not exist, the guidelines contained in this chart are utilized. 

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 1-855-799-2551. You can include any medical records that will support your request.

Coming soon.

MDHHS is partnering Aetna Better Health® in the We Treat HEP C Initiative

Hep C treatment no longer requires a prior authorization if using the State Preferred PDL agent Mavyret®. Hep C treatment is carved out to MDHHS fee for service (MagellanRx) and as 4/1/2021 the system is set up to approve Mavyret® for up to a 12 week supply. Network pharmacies have also been made aware of the changes to the PA status of Mavyret® and should be prepared to dispense accordingly.

Please see the below FAQ for further information for prescribers of Mavyret ® as part of the We Treat HEP C Initiative:

  1. Which type of provider may prescribe Mavyret®?
    • All MDHHS registered prescribers, including non-specialists, will be able to prescribe Mavyret® as of 4/1/2021
  2. What has to be submitted with a MAVYRET® claim now that no PA is required?
  3. Will MAVYRET® be covered without a PA in the rare case a patient requires 12 weeks of therapy?
    • Yes
  4. For patients currently taking another Direct-Acting Antiviral (DAA) therapy (Zepatier, Epclusa, etc.), will they be able to complete their course of therapy (i.e., refills)?
    • Yes
  5. Will there be specific PA criteria listed in the PDL for the non-preferred DAAs?
    • Non-preferred DAAs will require a PA explaining why MAVYRET® is not clinically appropriate: MIRx_PAfaxform_General.pdf (magellanrx.com)
  6. Are prisoners covered by Medicaid upon release and therefore able to get MAVYRET® without a PA?
    • We are working on a Targeted Case Management benefit that provides support and resources for individuals recently released from a correctional facility, including some degree of in-reach, but this has not yet been implemented.
  7. Can patients fill their MAVYRET® prescription at any Specialty or Retail Pharmacy?
    • Yes
  8. What is the co-pay for MAVYRET® under this agreement? What is the co-pay for a non-preferred DAA?
    • For Medicaid, co-pay for MAVYRET® is $1, and co-pay for non-preferred DAAs are $3. There are no co-pays for viral hepatitis treatments for Healthy Michigan Plan.
  9. Can more than 4 weeks of therapy be prescribed at a single time (e.g., 8 weeks of therapy, or less frequently 12 weeks of therapy, as opposed to 4 weeks with refill(s))?
    • Pharmacies are authorized to dispense up to 102 days of therapy at a single time. However, many pharmacies may default to dispensing in 4-week increments, unless the script specifies an 8- or 12-week supply.   
  10. Is MAVYRET® covered for patients on Emergency Services Only (ESO) Medicaid?
    • Yes. MAVYRET® is covered for beneficiaries on Emergency Service (ESO) Medicaid. The Pharmacy should indicate level of service 3 (emergency) on the claim.

Aetna Better Health of Michigan participates in the Medicaid Health Plan Common Formulary. Under the Common Formulary, Medicaid Health Plan formulary coverage is limited to products with a National Drug Code from manufacturers who participate in the Medicaid Drug Rebate Program. The following Medicaid Drug Rebate Program reference is reproduced from the Drug Manufacturer Contacts reference located on medicaid.gov.

A manufacturer’s labeler code is represented in the first five digits of a product’s NDC. Formulary NDCs included under a manufacturer’s labeler code are covered according to formulary coding established under the Common Formulary.

If a NDC for a non-MDRP participating labeler is adjudicated on a pharmacy claim, NCPDP error AC (Product Not Covered non-Participating Manufacturer) will be included in the reject messaging.

Aetna Better Health of Michigan may consider making medical necessity accommodations for members who need a non-MDRP participating NDC when all formulary NDCs are unavailable. Prescribers must submit a prior authorization request through the CoverMyMeds® website or find the prior authorization forms here. For urgent needs, pharmacies can call the CVS Caremark Pharmacy Help Desk for assistance at 1-855-432-6843.

Please note: This reference is up to date as of the date included in the footer below. Updates to the MDRP may occur multiple times each week. For a current list of additional updates, please visit the New/Reinstated & Terminated Labeler Information reference on the Medicaid.gov website. Medicaid Health Plans apply the optional effective date for new/reinstated labelers. Labelers listed for termination are removed from coverage according to the effective date presented on the Terminated Labelers table.

 

MHP Monthly MDRP Labeler List

ABH of MI covers antiviral treatment for COVID-19 through the pharmacy benefit. Please click here for more information about COVID-19 antiviral treatment. Pharmacists and Providers may click here for additional COVID-19 therapeutic information.

Need information about medication recalls?  Just call the U.S. Food and Drug Administration (FDA) at 1-888-463-6332.  Or visit the drug recalls page on the FDA website.