Pharmacy

Aetna Better Health’s Formulary Drug Lists

 

Medicaid Members

When considering medications, you and your doctor should try to use drugs that are designated as preferred on the Statewide Preferred Drug List (PDL).  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.

Aetna Better Health of Pennsylvania also covers drugs and products that are not on the DHS PDL.  This is called the Supplemental Formulary.  Click here to look at this list or use our Supplemental Formulary Search Tool.

 

Aetna Better Health Kids

To prevent extra costs, check that your medicines are on the preferred drug list.  This list is called the formulary.

To view medicines that are covered on the formulary, you can search for drugs using our Formulary Search Tool.  Searches can be performed by drug name or drug class.  The tool will provide formulary status and if there are any clinical edits (Prior Authorization, Quantity Level Limits, Age Limits, etc.).

 

All Members

The formularies can change.  You can see a list of added or removed drugs by reading the formulary updates below.

Ask your doctor to review the Formulary Drug List for any restrictions or recommendations regarding prescription drugs before prescribing a drug for you. Then, make sure you get your prescriptions filled at an Aetna Better Health network pharmacy. The Member Handbook tells you how much you have to pay for your medicines based on your pharmacy benefit.

You can learn about potential drug interactions, side effects and risks of the medicines you take. Just visit Krames Online and MedlinePlus.

Find a pharmacy provider

You can find the location of an in-network pharmacy by visiting the CVS Caremark pharmacy locator. This allows you to search for a pharmacy by zip code so you can find a location close to you.

Other drug lists

Careful handling and quick delivery for specialty drugs

Our preferred Specialty Pharmacy providers are Accuserv Pharmacy, Caremark Specialty Pharmacy, Einstein at Center One Pharmacy, Elwyn Specialty Care, Giant Eagle Pharmacy, Pharmblue LLC and Senderra Rx Pharmacy.

These pharmacies fill prescriptions for Specialty Drugs .* These types of drugs may be injected, infused or taken by mouth. Usually, you can't get these drugs at a local retail pharmacy. They often need special storage and handling. And they need to be delivered quickly.

Our preferred Specialty Pharmacies provide many helpful services, including:

  • Free, secure delivery (usually within 48 hours of confirming your order)
  • Delivery to your home, doctor’s office or any other place you choose
  • Package tracking for prompt delivery
  • Training on how to self-inject your medicine
  • Free injection supplies, such as needles, syringes, alcohol swabs, adhesive bandages and containers for needle waste

How to get started

We have several ways for you to fill a prescription through one of our preferred Specialty Pharmacies.

Existing prescriptions: To transfer an existing prescription, call one of our Preferred Specialty pharmacies.

New prescriptions: For a new prescription, your doctor can:

  • Send a prescription electronically.
  • Fax your prescription
  • Call one of preferred specialty pharmacies
  • You or the doctor can mail the prescription order.

After the pharmacy receives your prescription, your first order should ship within 48 hours. It may take longer if they need to contact your doctor about the prescription. 

Accuserv Pharmacy

Caremark Specialty Pharmacy

Einstein at Center One Pharmacy

Elwyn Specialty Care

Giant Eagle Pharmacy

Pharmblue LLC

  • You or your doctor can visit the web site for an enrollment form: https://www.pharmblue.com
  • Phone: 855-779-4720
  • Fax: 844-818-7550

Senderra Rx Pharmacy

A personal care plan and ongoing support

Each of our preferred Specialty Pharmacies has a team of experienced nurses and pharmacists to help you understand how to use your medicine. They can answer your questions and help you cope with your condition throughout your therapy.

You can talk to them 24 hours a day, 7 days a week.

Get extra support for your complex medical condition

Skilled nurses and pharmacists offer extra support to patients with complex medical conditions, such as the any of the following:

  • Anemia
  • Asthma
  • Cancer
  • Chronic renal failure
  • Crohn's disease
  • Gaucher disease
  • Growth hormone deficiency
  • Hematologic conditions
  • Hemophilia
  • Hepatitis
  • HIV/AIDS
  • Immune system disorders
  • Multiple sclerosis
  • Neurologic conditions
  • Osteoarthritis
  • Psoriasis
  • Pulmonary diseases
  • Respiratory syncytial virus (RSV)
  • Rheumatoid arthritis
  • Transplant

Joining our preferred Specialty Pharmacy network

Are you a pharmacy interested in joining our preferred specialty pharmacy network? You can get the application process started by sending an email to Specialtypharmacyapplications@cvscaremark.com. Thank you for your interest in supporting our commitment to high-quality care.

Updates are made regularly to the Statewide Preferred Drug List.

January 2021

Removals:

  • Hydroxyurea Cap 500mg
  • Hydroxyurea Cap 500mg
  • Glucagon (RDNA) For Inj Kit 1 Mg
  • Glucagon HCl (RDNA) For Inj 1mg (Base Equiv)
  • Estradiol Vaginal Tab 10 Mcg
  • Estradiol Vaginal Cream 0.1 mg/gm
  • Estradiol Vaginal Ring 2 Mg (7.5mcg/24hrs)
  • Hydroxyurea Cap 200mg
  • Hydroxyurea Cap 300mg
  • Hydroxyurea Cap 400mg

 

December 2020

No Updates

 

November 2020

No Updates

 

October 2020

No Updates

 

September 2020

No Updates

 

August 2020

No Updates

 

July 2020

No Updates

 

June 2020

No Updates

 

May 2020

No Updates

 

April 2020

No Updates

 

March 2020

No Updates

 

February 2020

Additions:

  • Centrum Kids Chewable Tab
  • DEKAs Plus Cap
  • DEKAs Plus Liquid
  • Docusate Sodium Cap 50mg
  • Mineral Oil Enema
  • Multivitamin with Minerals Tab
  • MVW Complete Formulation Solution 45mg/0.5ml

 

January 2020

Additions:

  • Aspirin EC Tabs 81mg, 325mg
  • Aspirin Tabs 81mg, 325mg
  • BD Pen Needles
  • Lancets, Lancet Kits, Lancet Devices
  • Tums Chewable Tabs 500mg, 750mg, 1000mg (Brand Name)

Removals:

  • Hydrocortisone Rectal Cream 1%
  • Omega-3 Fatty Acids Cap 1400mg

January 2021

Additions:

  • Retacrit Inj 20000uni (Prior Authorization Required)

Removals:

  • None

Other Updates:

  • None

 

December 2020

Additions:

  • Trelegy Aer Ellipta 200-62.5-25mcg/inh (Quality Level Limit, Step Therapy Required)

Removals:

  • None

Other Updates:

  • None

 

November 2020

Additions:

  • Dimethyl Fum Cap 120mg DR (Quantity Level Limit, Prior Authorization Required)
  • Dimethyl Fum Cap 240mg DR (Quantity Level Limit, Prior Authorization Required)
  • Dimethyl Fumarate Capsule DR Starter Pack 120 Mg & 240 Mg (Quantity Level Limit, Prior Authorization Required)
  • Emtricitabin Cap 200mg (Prior Authorization Required)

Removals:

  • Emtriva Cap 200mg
  • Tecfidera Cap 120mg DR
  • Tecfidera Cap 240mg DR
  • Tecfidera Capsule DR Starter Pack 120 Mg & 240 Mg

Other Updates:

  • None

 

October 2020

Additions:

  • Efavirenz-Lamivudine-Tenofovir Df Tab 400-300-300mg
  • Efavirenz-Lamivudine-Tenofovir Df Tab 600-300-300mg

Removals:

  • Symfi Lo Tablet 400-300-300mg
  • Symfi Tablet 600-300-300mg

Other Updates:

  • None

 

Septmeber 2020

Additions:

  • Abiraterone Tab 250mg (Prior Authorization Required)
  • Alecensa Cap 150mg (Prior Authorization Required)
  • Austedo Tabs 5mg, 9mg, 12mg (Prior Authorization Required)
  • Budesonide Cap 3mg (Step Therapy Required, Quantity Level Limit)
  • Caprelsa Tabs 100mg, 300mg (Prior Authorization Required)
  • Cinacalcet Tabs 30mg, 60mg, 90mg (Prior Authorization Required)
  • Cyclophosphamide Caps 25mg, 50mg
  • Enbrel Injection 25mg (Prior Authorization Required, Quantity Level Limit)
  • Erivedge Cap 150mg (Prior Authorization Required)
  • Gilotrif Tabs 20mg, 30mg, 40mg (Prior Authorization Required)
  • Jakafi Tabs 5mg, 10mg, 15mg, 20mg, 25mg (Prior Authorization Required)
  • Kalydeco Pak 25mg, 50mg, 75mg (Prior Authorization Required)
  • Kalydeco Tab 150mg (Prior Authorization Required)
  • Lenvima Caps 4mg, 8mg, 10mg, 12mg, 14mg, 18mg, 20mg, 24mg (Prior Authorization Required)
  • Linezolid Tab 600mg (Prior Authorization Required)
  • Mekinist Tabs 0.5mg, 2mg (Prior Authorization Required)
  • Ofev Caps 100mg, 150mg (Prior Authorization Required)
  • Repatha Injection 140mg/ml, 420mg/3.5ml (Prior Authorization Required)
  • Rydapt Cap 25mg (Prior Authorization Required)
  • Symdeko Tabs 50-75mg, 100-150mg (Prior Authorization Required)
  • Tafinlar Caps 50mg, 75mg (Prior Authorization Required)
  • Venclexta Start Pack (Prior Authorization Required)
  • Venclexta Tabs 10mg, 50mg, 100mg (Prior Authorization Required)
  • Xolair Injection 75mg/0.5ml, 150mg/ml (Prior Authorization Required)
  • Zykadia Cap 150mg (Prior Authorization Required)

Removals:

  • None

Other Updates:

  • Soliris Injection 10mg/ml (Prior Authorization Required)
  • Proton Pump Inhibitors (Quantity Level Limit)

 

August 2020

Additions:

  • Amitiza Caps 8mcg, 24mcg (Prior Authorization Required, Quantity Level Limit)
  • Buprenorphine Weekly Patches 5mcg, 7.5mcg, 10mcg, 15mcg, 20mcg (Prior Authorization Required, Quantity Level Limit)
  • Diclofenac Sodium Solution 1.5% (Step Therapy, Quantity Level Limit)
  • Ibrance Caps 75mg, 100mg, 125mg (Prior Authorization Required, Quantity Level Limit)
  • Ibrance Tabs 75mg, 100mg, 125mg (Prior Authorization Required, Quantity Level Limit)
  • Lynparza Tabs 10mg, 15mg (Prior Authorization Required, Quantity Level Limit)
  • Omeprazole OTC Tab 20mg (Generic)
  • Poly-Vi-Sol Solution 50mg/ml
  • Solifenacin Succinate Tabs 5mg, 10mg (Step Therapy, Quantity Level Limit)
  • Symproic Tab 0.2mg (Prior Authorization Required, Quantity Level Limit)
  • Testosterone TD Solution 30mg/actuation (Prior Authorization Required, Quantity Level Limit)
  • Tivicay PD Tab 5mg (Diagnosis Confirmation Required, Age Limit)
  • Trelegy Ellipta (Step Therapy, Quantity Level Limit)
  • Tri-Vi-Sol Solution A/C/D

Removals:

  • Cimduo Tab 300-300mg
  • Fluocinolone Acetonide Solution 0.01%
  • Fluorouracil Cream 0.5%
  • Humulin 70/30
  • Humulin N
  • Humulin R
  • Kitabis Nebule Solution 300mg/5ml
  • Naproxen Sodium Tab 275mg
  • Nimodipine Cap 30mg
  • Prilosec OTC Tab 20mg (Brand)
  • Targretin Gel 1%
  • Tolmetin Sodium Cap 400mg
  • Tolmetin Sodium Tabs 200mg, 600mg

Other Updates:

  • Adapalene Gel 0.1% (Removed Step Therapy from Rx Product)
  • Athletes Foot (Miconazole Nitrate) Powder 2% (Quantity Level Limit)
  • Auryxia Tab 210mg (Step Therapy Required)
  • Betamethasone Dipropionate Augmented Cream 0.05% (Quantity Level Limit)
  • Betamethasone Dipropionate Cream 0.05% (Quantity Level Limit)
  • Betamethasone Dipropionate Lotion 0.05% (Quantity Level Limit)
  • Betamethasone Valerate Cream 0.1% (Quantity Level Limit)
  • Betamethasone Valerate Lotion 0.1% (Quantity Level Limit)
  • Betamethasone Valerate Ointment 0.1% (Quantity Level Limit)
  • Butenafine HCL Cream 1% (Quantity Level Limit)
  • Candesartan Cilexetil – Hydrochlorothiazide Tabs 16-12.5mg, 32-12.5mg, 32-25mg (Step Therapy Required)
  • Candesartan Cilexetil Tabs 4mg, 8mg, 16mg, 32mg (Step Therapy Required)
  • Ciclopirox Olamine Cream 0.77% (Quantity Level Limit)
  • Ciclopirox Olamine Suspension 0.77% (Quantity Level Limit)
  • Ciclopirox Shampoo 1% (Quantity Level Limit)
  • Ciclopirox Solution 8% (Quantity Level Limit)
  • Ciprofloxacin HCL OTIC Solution 0.2% (Quantity Level Limit)
  • Clindamycin Phosphate Gel 1% (Quantity Level Limit)
  • Clindamycin Phosphate Lotion 1% (Quantity Level Limit)
  • Clindamycin Phosphate Solution 1% (Quantity Level Limit)
  • Clindamycin Phosphate Swab 1% (Quantity Level Limit)
  • Clotrimazole Cream 1% (Quantity Level Limit)
  • Clotrimazole Solution 1% (Quantity Level Limit)
  • Clotrimazole-Betamethasone Cream 1-0.05% (Quantity Level Limit)
  • Disulfiram Tabs 250mg, 500mg (Quantity Level Limit)
  • Ear Drops (Carbamide Peroxide) OTIC Solution 6.5% (Quantity Level Limit)
  • Ery Pad (Erythromycin) 2% (Quantity Level Limit)
  • Erythromycin Gel 2% (Quantity Level Limit)
  • Erythromycin Solution 2% (Quantity Level Limit)
  • Flunisolide Nasal Solution 25mcg/Actuation (Step Therapy Required)
  • Fluocinonide Cream 0.05% (Quantity Level Limit)
  • Fluocinonide Solution 0.05% (Quantity Level Limit)
  • Fluvastatin Sodium Caps 20mg, 40mg (Step Therapy Required)
  • Hydrocortisone Cream 0.5%, 1%, 2.5% (Quantity Level Limit)
  • Hydrocortisone Lotion 1%, 2.5% (Quantity Level Limit)
  • Hydrocortisone Ointment 0.5%, 1%, 2.5% (Quantity Level Limit)
  • Hydrocortisone-Acetic Acid OTIC Solution 1-2% (Quantity Level Limit)
  • Ketoconazole Cream 2% (Quantity Level Limit)
  • Ketoconazole Shampoo 2% (Quantity Level Limit)
  • Lidocaine Ointment 5% (Quantity Level Limit)
  • Linzess Caps 72mcg, 145mcg, 290mcg (Prior Authorization Required)
  • Liothyronine Sodium Tab 25mcg (Quantity Level Limit)
  • Miconazole Nitrate Aerosol Powder 2% (Quantity Level Limit)
  • Miconazole Nitrate Cream 2% (Quantity Level Limit)
  • Mometasone Furoate Cream 0.1% (Quantity Level Limit)
  • Mometasone Furoate Ointment 0.1% (Quantity Level Limit)
  • Mometasone Furoate Solution 0.1% (Quantity Level Limit)
  • Naltrexone Tab 50mg (Quantity Level Limit)
  • Neomycin-Polymixin-HC OTIC Solution 1% (Quantity Level Limit)
  • Neomycin-Polymixin-HC OTIC Suspension 3.5mg/ml-10000 Unit/ml (Quantity Level Limit)
  • Nystatin Cream 100,000 Units/Gm (Quantity Level Limit)
  • Nystatin Ointment 100,000 Units/Gm (Quantity Level Limit)
  • Nystatin Powder 100,000 Units/Gm (Quantity Level Limit)
  • Ofloxacin OTIC Solution 0.3% (Quantity Level Limit)
  • Permethrin Cream 5% (Quantity Level Limit)
  • Prednicarbate Ointment 0.1% (Quantity Level Limit)
  • Proton Pump Inhibitors (Quantity Level Limit)
  • Ropinirole Hydrochloride Extended Release Tabs 2mg, 4mg, 8mg, 6mg, 12mg (Step Therapy Required)
  • Scalp Relief Max Strength (Hydrocortisone 1%) Solution (Quantity Level Limit)
  • Stop Lice Maximum Strength (Pyrethrins-Piperonyl Butoxide) Liquid 0.33-4% (Quantity Level Limit)
  • Sulfacetamide Sodium (Acne) Lotion 10% (Quantity Level Limit)
  • Terbinafine HCL Cream 1% (Quantity Level Limit)
  • Testosterone Gel 1.62% (Prior Authorization Required, Quantity Level Limit)
  • Tolnaftate Cream 1% (Quantity Level Limit)
  • Triamcinolone Acetonide Cream 0.025%, 0.1%, 0.5% (Quantity Level Limit)
  • Triamcinolone Acetonide Lotion 0.0.25%, 0.1% (Quantity Level Limit)
  • Triamcinolone Acetonide Ointment 0.025%, 0.05% (Quantity Level Limit)

 

July 2020

Additions:

  • Gvoke PFS Injection 0.5mg/0.1ml (Quantity Level Limit)
  • HM Urinary Pain Relief (Phenazopyridine) Tab 99.5mg

 

June 2020

Additions:

  • Acne Medication Lotion (Benzoyl Peroxide) 10%
  • Alahist D Tab
  • Atovaquone-Proguanil Tabs (Quantity Level Limit)
  • Claravis Caps 10mg, 20mg, 30mg, 40mg (Step Therapy, Quantity Level Limit)
  • Dovato Tab 50-300mg (Diagnosis Confirmation Required, Quantity Level Limit)
  • Gvoke Hypopen Injection (Quantity Level Limit)
  • Isotretinoin Caps 10mg, 20mg, 30mg, 40mg (Step Therapy, Quantity Level Limit)
  • Jock Itch/Athlete’s Foot Spray (Tolnaftate) Aerosol Powder 1% (Quantity Level Limit)
  • Phenazopyridine Tab 95mg
  • Primaquine Tab 26.3mg (Quantity Level Limit)
  • Tolnaftate Powder 1% (Quantity Level Limit)

Removals:

  • Clotrimazole Solution 1% - RX (Removed Step Therapy)

 

May 2020

Additions:

  • Dexamethasone Concentrate Solution 1mg/ml
  • Dexamethasone Vials 4mg/ml, 10mg/ml, 20mg/5ml, 120mg/30ml
  • Hydrocortisone Sodium Succinate PF Vials 100mg, 250mg, 500mg, 1000mg
  • Pyrethrins-Piperonyl Butoxide Shampoo 0.33-4% (Quantity Level Limit)
  • Pyrimethamine Tab 25mg (Prior Authorization Required)

Removals:

  • Ala Scalp Lotion 2%
  • Daraprim Tab 25mg (Brand)

 

April 2020

Additions:

  • Aripiprazole Tabs 2mg, 5mg, 10mg, 15mg, 20mg, 30mg (Age Limit, Quantity Level Limit)
  • Budesonide-Formoterol Inhalers 80-4.5mcg, 160-4.5mcg (Quantity Level Limit)
  • Novolin R FlexPen 100 units/ml
  • Omeprazole Disintegrating Tablet 20mg (Quantity Level Limit)
  • Orkambi Granules 100-125mg, 200-125mg (Prior Authorization Required)
  • Orkambi Tabs 100-125mg, 200-125mg (Prior Authorization Required)
  • Tramadol Tab 100mg (Quantity Level Limit)

Removals:

  • Carafate Suspension 1gm/10ml (Brand)

 

March 2020

Additions:

  • Mesalamine Cap 0.375gm
  • Penicillamine Tab 250mg (Prior Authorization Required, Quantity Level Limit)

Removals:

  • Apriso Cap 0.375gm (Brand)

Other Updates:

  • Prenatal Vitamin Tabs (Quantity Level Limit)

 

February 2020

Additions:

  • Bimatoprost Ophthalmic Solution 0.03% (Step Therapy Required)
  • Ethinyl Estradiol – Etonogestrel Ring 0.015mg-0.12mg (Quantity Level Limit)
  • Everolimus Tabs 2.5mg, 5mg, 7mg (Prior Authorization Required)
  • Liletta IUD 19.5mcg/day

Removals:

  • Afinitor Tab 2.5mg, 5mg, 7.5mg (Brand)
  • Alprazolam Concentrate Solution 1mg/ml
  • Chlorothiazide Tabs
  • Demeclocycline Tabs
  • Doxycycline Monohydrate Tab 150mg
  • First-Vanco Solution 25mg/ml, 50mg/ml
  • Homatropine Ophthalmic Solution 5%
  • Kyleena IUD
  • Methylclothiazide Tab 5mg
  • Mirena IUD
  • Nausea Relief Liquid
  • Nizatidine Solution 15mg/ml
  • Nuvaring (Brand)
  • Phospholine Ophthalmic Solution 0.125%
  • Propantheline Cap 15mg
  • Rabeprazole EC Cap 20mg
  • Ranitidine Caps 150mg, 300mg
  • Skyla IUD

Other Updates:

  • Atropine Ophthalmic Ointment 1% (Quantity Level Limit)
  • Atropine Ophthalmic Solution 1% (Quantity Level Limit)
  • Buspirone Tabs 5mg, 7.5mg, 10mg, 15mg (Age Limit)
  • Combigan Ophthalmic Solution 0.5/0.5% (Quantity Level Limit)
  • Diazepam Concentrate 5mg/ml (Quantity Level Limit)
  • Diazepam Oral Solution (Quantity Level Limit)
  • Diazepam Tabs 2mg, 5mg, 10mg (Quantity Level Limit)
  • Divalproex ER Tab 250mg, 500mg (Prior Authorization Required)
  • Dorzolamide-Timolol Ophthalmic Solution 22.3-6.8% (Quantity Level Limit, Step Therapy Required)
  • Doxycycline Monohydrate Suspension 25mg/5ml (Age Limit)
  • Granisetron Tab 1mg (Step Therapy Required)
  • Hydroxyzine Pamoate Caps 25mg, 50mg, 100mg (Quantity Level Limit)
  • Hydroxyzine Tab 50mg (Quantity Level Limit)
  • Levofloxacin Ophthalmic Solution 0.5% (Quantity Level Limit)
  • Lorazepam Concentrate 2mg/ml (Age Limit, Quantity Level Limit)
  • Memantine Tabs 5mg, 10mg (Quantity Level Limit)
  • Methazolamide Tabs 25mg, 50mg (Step Therapy Required)
  • Natacyn Ophthalmic Suspension 5% (Quantity Level Limit)
  • Tazarotene Cream 1% (Step Therapy Required)
  • Timolol Ophthalmic Gel Solution 0.25%, 0.5% (Quantity Level Limit)
  • Trifluridine Ophthalmic Solution 1% (Quantity Level Limit)

 

 

January 2020

Additions:

  • Buprenorphine-Naloxone Films 2-0.5mg, 4-1mg, 8-2mg, 12-3mg (Quantity Level Limit)

Removals:

  • Ventolin HFA Inhaler (brand name)

Learn more about prescription drug coverage