Pharmacy

Formulary/Preferred Drug Lists

 

Medicaid Member Preferred Drug List

For Medicaid members, the list of covered drugs is the Statewide Preferred Drug List (PDL) from the Pennsylvania Department of Human Services (DHS). 

Aetna Better Health of Pennsylvania also covers drugs and products that are not on the DHS Preferred Drug List.  This list is called the supplemental formulary.  You also have the ability to search the supplemental formulary by using the supplemental formulary search tool.

Please review the PDL, Quantity Level Limits document, and/or supplemental formulary for restrictions or recommendations regarding prescription drugs before prescribing a medication to an Aetna Better Health of Pennsylvania member.

Prescriptions must be filled at an Aetna Better Health network pharmacy, and other plan rules must be followed.

To initiate an electronic prior authorization (ePA), please click here.

 

Aetna Better Health Kids Preferred Drug List

The Formulary is a list of drugs chosen by Aetna Better Health and a team of doctors and pharmacists that are generally covered under the plan as long as they are medically necessary. Prescriptions must be filled at an Aetna Better Health network pharmacy, and other plan rules must be followed. View our latest formulary drug list.

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).

Please review the Formulary for any restrictions or recommendations regarding prescription drugs before prescribing a medication to an Aetna Better Health patient.  To initiate an electronic prior authorization (ePA), please click here.

 

Visit Pharmacy Provider Search to view all the Aetna Better Health pharmacy providers.

 

Check back frequently as the formulary, prior authorization guidelines, and prior authorization forms are updated regularly.

You can view a list of recent formulary updates below.

Updates are made regularly to the Statewide Preferred Drug List.

Medicaid Supplemental Formulary Updates

Formulary changes include the following:

  • Addition/removal of a drug from the formulary
  • Addition/removal of quantity level limits
  • Addition/removal of prior authorization requirements

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

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)
  • Emtricitabin Cap 200mg (Prior Authorization Required)

Removals:

  • Emtriva Cap 200mg
  • Tecfidera Cap 120mg DR
  • Tecfidera Cap 240mg DR

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)
  • 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)

 

 

December 2019

Removals:

  • PreNata Chewable Tab 29-1mg

 

 

November 2019

No Updates

Prior authorization for drugs

If the drug you are requesting is a statewide PDL drug, use the Universal Pharmacy Prior Authorization Fax Form, or appropriate drug specific form. 

If the drug you are requesting is an Aetna supplemental drug, use the Universal Pharmacy Prior Authorization Fax Form, or appropriate drug specific form.

To initiate an electronic prior authorization (ePA) request, please click here.

To quickly find a prior authorization form, click "CTRL F" on your keyboard and type in the form name.

Universal Pharmacy Prior Authorization Fax Form

 

Acamprosate

Actimmune 

Analgesics-Non-Opioid Barbiturate Combinations  

Analgesics-Opioids Long-Acting  

Analgesics-Opioids Short-Acting 

Antidepressants, Other  

Antihemophilia Agents  

Antipsychotics  

Blood Glucose Meters and Test Strips  

Botulinum Toxins  

Colony Stimulating Factors  

Cystic Fibrosis  

Cytokine and CAM Antagonists 

Daraprim 

Dupixent  

Erythropoiesis Stimulating Proteins  

Hepatitis C Agents 

Intra-Articular Hyaluronates  

Interferons   Updated 03.20.2020

Monoclonal Antibodies Anti-IL, Anti-IgE  

Multiple Sclerosis  

Non-Preferred Medication 

Nuedexta  Updated 03.20.2020

Oncology Agents, Oral  

Opioid Dependence Treatments, Oral  

Opioid Dependence Treatments, Probuphine  

Opioid Dependence Treatments, Sublocade  

Pituitary Suppressive Agents, LHRH  

Sensipar

Somatostatin Analogs  Updated 03.20.2020

Stimulants and Related Agents 

Stimulants and Related Agents, Provigil, Nuvigil  

Synagis 

Zolgensma New 03.20.2020

 

If the drug you are requesting is not listed below, use the Universal Pharmacy Prior Authorization Fax Form . Also view our list of Step Therapy guidelines.  To initiate an electronic prior authorization (ePA) request, please click here.

To quickly find a prior authorization form, click "CTRL F" on your keyboard and type in the form name. 

Universal Pharmacy Prior Authorization Fax Form CHIP

 

Antidepressants   

Atypical Antipsychotics Long-Acting Injectables  

Atypical Antipsychotics Oral  Updated 08.18.2020

Botulinum Toxins  

Buprenorphine Updated 08.18.2020

Calcitonin Gene-Related Peptide Receptor Antagonists  Updated 08.18.2020

CNS Stimulants (ADD/ADHD Medications)  

Colony Stimulating Factor  Updated 08.18.2020

Corlanor  

Cystic Fibrosis  

Cytokine and CAM Antagonists  Updated 06.08.2020

Dalfampridine (Ampyra) 

Daliresp 

Daraprim (Pyrimethamine)  Updated 08.18.2020

DPP-4 Inhibitors

Dupixent  

Egrifta  

Emflaza  

Entresto  

Epidiolex  

Erythropoiesis Stimulating Agents  

Gonadotropin Releasing Hormone Analogs  

Growth Hormone   

Hemophilia  New 08.18.2020

Hepatitis C   Updated 08.18.2020

Hyaluronic Acid Derivatives  

Hyperlipidemia Medications (Epanova, Lovaza, Vascepa)

IL-5 Antagonists

Increlex  

Injectable Osteoporosis  

Interferons New 08.18.2020

Janus Associated Kinase Inhibitors  

Monoamine Depletors (Austedo, Ingrezza, tetrabenzaine) 

Multiple Sclerosis Agents   

Nuedexta

Omega 3 carboxylic acids (Epanova)

Opioids Long and Short Acting  Updated 08.18.2020

PCSK9 Inhibitors 

Platelet Inhibitors 

Promacta  Updated 08.18.2020

Pulmonary Arterial Hypertension  Updated 08.18.2020

Rosuvastatin

Savella

Somatostatin analogs

Synagis 

Tavalisse

Testosterone  Updated 08.18.2020

Topical Hyaluronic Acid Derivatives

Vivitrol  New 08.18.2020

Xolair  

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: (Medicaid) RX8813

Group: (CHIP) RX8814

Aetna Better Health used the Department of Human Services (DHS) Drug Criteria and our custom Prior Authorization Guidelines to make decisions when you send in a request for a drug on the Statewide PDL/formulary that needs a review prior to being dispensed. To have a copy of these guidelines sent to you or to have any questions answered, just call:

Medicaid Provider Relations at 1-866-838-1232

 

Aetna's Custom Prior Authorization Guidelines

Acamprosate (PARP approved 06/2018)       

Anthelimintics (PARP approved 03/2019)                                                                                                                                                                                                              

Continuous Glucose Monitoring (PARP approved 05/2020)

Compound Guideline (PARP approved 12/2019)

Corlanor (PARP approved 02/2019)

Cystic Fibrosis (PARP approved 02/2019)

Daraprim (PARP approved 06/2018)    

Egrifta (PARP approved 03/2019)

Elmiron (PARP approved 06/2018)

Exondys-Vyondys (PARP approved 05/2020)

Generic Substitution (PARP approved 12/2019)                                        

HP Acthar (PARP approved 12/2019)                                              

Interferons (non-Hepatitis C) (PARP approved 12/2019)  

IVIG Products  (PARP approved 12/2019) 

Korlym (PARP approved 02/2019)

L-Methylfolate Products (PARP approved 12/2019

Lucemyra (PARP approved 02/2019)                                                 

Multaq (PARP approved 02/2019)

Non-Formulary Medication (PARP approved 12/2019)

Nuedexta (PARP approved 12/2019)

Off Label Use (PARP approved 12/2019)

Quantity Limits (PARP approved 02/2019)

Sensipar (PARP approved 06/2018)

Somatostatin Analogs  (PARP approved 12/2019)

Spinraza (PARP approved 05/2020)

Synagis (PARP approved 12/2019)

Tranexamic Acid (PARP approved 02/2019)

Trial Dose Program (PARP approved 10/2014)

Zolgensma (PARP approved 12/2019)

 

 

To quickly find a prior authorization guideline, click "CTRL F" on your keyboard and type in the guideline name.

Non-Formulary and Prior Authorization Guidelines (effective 09.01.2020)

                                       

Antihyperlipidemics                                                                           

Botulinum Toxins   (effective 04.01.2020)                                    

Buprenorphine                            

Colony Stimulating Factors (effective 08.18.2020)                      

Compound Guideline 

Cytokine and CAM Antagonists (effective 06.08.2020)

Daliresp 

Diabetic Testing Supplies       

Growth Hormone  (effective 04.01.2020)                                         

Hepatitis C (effective 08.18.2020)

Hereditary Angioedema Agents (effective 04.01.2020)                                 

Immune Globulins (effective 04.01.2020)

Injectable Osteoporosis Agents (effective 04.01.2020)          

Interleukin-5 Antagonist                                    

Multiple Sclerosis Agents (effective 06.08.2020)

Nuedexta 

Opioids Long and Short Acting (effective 08.18.2020)

Platelet Inhibitors 

Pulmonary Fibrosis Agents 

Ranexa 

Restasis and Xiidra 

Somatostatin Analogs  

Synagis 

Tavalisse 

Trial Dose Program 

Xolair 

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.

Specialty locations

The step therapy program requires certain first-line drugs, such as generic drugs or formulary brand drugs, to be prescribed prior to approval of specific, second-line drugs. Drugs with step therapy guidelines are identified on the formulary as “STEP.”

To request an override for the step therapy, please fax the correct pharmacy Prior Authorization request form to 1-877-309-8077. You can include any supporting medical records that will assist with the review of the request.

Coming Soon!

The Aetna Better Health® of Pennsylvania/Kids Pharmacy & Therapeutics (P&T) Committee develops and reviews the supplemental formulary (Medicaid) and the formulary for CHIP.  The committee also reviews all clinical criteria for utilization management.  All P&T changes for the supplemental formulary are submitted to the Department for review and approval prior to implementation.

Pharmacy Provider Appeals

You can request Aetna Better Health for a second level appeal after your pricing appeal to the pharmacy benefit manager (PBM) has been denied.

For questions concerning the Provider Appeal process, contact the Provider Appeal Department at 1-860-754-1757.

To submit a formal Provider Appeal in writing, send to the address below:

 

Aetna Better Health of Pennsylvania

Attention: Provider Appeals

2000 Market Street, Suite 850

Philadelphia, PA 19103

 

Submission steps:

  1. Submit the appeal in writing to Aetna Better Health to the address above.
  2. Include all supporting documentation with the appeal submission:
    1. Chains/PSAOs
      1. Documentation of denied Pricing Appeal outcome from the PBM
      2. Documentation that outreach regarding the denied outcome of appeal has been made to their PSAO or Corporate Headquarters with no resolution
    2. Independent Pharmacies not affiliated with a PSAO
      1. Documentation of denied Pricing Appeal outcome from the PBM
    3. Claim information that includes:
      1. Pharmacy NCPDP number
      2. Pharmacy Name
      3. Name of PSAO (if applicable)
      4. Prescription number
      5. NDC
      6. Drug Name
      7. Date of Fill
    4. Documentation of pricing information from at least two (2) wholesalers, if applicable, inclusive of any additional rebates or discounts, showing that the wholesaler prices are not equal to or less than the MAC price
  3. We will acknowledge a Pharmacy Provider Appeal within five (5) business days after receipt.
  4. The appeal documentation will be reviewed, and a decision will be rendered within thirty (30) business days after receipt.
  5. Failure to submit support documentation may result in denial of the Provider Appeal.

Also, we have a Pharmacy Provider Appeals Committee to review and render a decision. The decision of the Provider Clinical Appeals Committee is final. We send decision notification letters to the requesting provider within five (5) business days of the committee decision. We will not take any punitive action against a provider for using the Provider Appeal Process.