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

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

 

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

 

October 2019

Other Updates:

  • Cetirizine Solution 1mg/ml (Quantity Level Limit)

 

September 2019

Additions:

  • Ambrisentan Tabs 5mg, 10mg (Prior Authorization Required, Quantity Level Limit)
  • Bosentan Tabs 62.5mg, 125mg (Prior Authorization Required, Quantity Level Limit)
  • Febuxostat Tabs 40mg, 80mg (Step Therapy Required)
  • Ramelteon Tab 8mg (Step Therapy Required, Quantity Level Limit)
  • Ribavirin Tab/Cap 200mg (Step Therapy Required)

Removals:

  • Letairis Tabs 5mg, 10mg (Brand)
  • Rozerem Tab 8mg (Brand)
  • Tracleer Tabs 62.5mg, 125mg (Brand)
  • Uloric Tabs 40mg, 80mg (Brand)

 

August 2019

Additions:

  • Aquadeks Drops
  • Butenafine Cream 1% (OTC)
  • Lidocaine Patch 4% (Quantity Level Limit)
  • Thyroid Tabs 180mg, 240mg, 300mg (Quantity Level Limit)

Removals:

  • Ciclopirox Gel 0.77%
  • Clotrimazole w/ Betamethasone Lotion 1-0.05%
  • Colestipol Granules 5gm
  • Epinastine Ophthalmic Solution 0.05%
  • Fluphenazine Elixir 2.5mg/5ml
  • Fluphenazine Injection 2.5mg/ml
  • Lindane Shampoo 1%
  • Moexipril Tabs 7.5mg, 15mg
  • Nitroglycerin Cap 2.5mg
  • Olopatadine Ophthalmic Solution 0.2%
  • Quinidine Gluconate CR Tab 324mg
  • Thyroid Tab 130mg

Other Updates:

  • Azelastine Ophthalmic Solution 0.05% (Quantity Level Limit)
  • Ciclopirox Cream 0.77% (Step Therapy Required)
  • Ciclopirox Shampoo 1% (Step Therapy Required)
  • Ciclopirox Suspension 0.77% (Step Therapy Required)
  • Fluocinolone Cream 0.025% (Quantity Level Limit)
  • Fluocinolone Ointment 0.025% (Quantity Level Limit)
  • Lidocaine Cream 4% (Quantity Level Limit)
  • Lidocaine Gel 2% (Quantity Level Limit)
  • Lidocaine-Prilocaine Cream 2.5-2.5% (Quantity Level Limit)
  • Liothyronine Tabs 5mcg, 50mcg (Quantity Level Limit)
  • Norethindrone Tab 5mg (Step Therapy Required)
  • Olanzapine ODT Tabs (Age Limit)
  • Olanzapine Tabs (Age Limit)
  • Quetiapine Tabs (Age Limit)
  • Risperidone ODT Tabs (Age Limit)
  • Risperidone Oral Solution 1mg/ml (Age Limit)
  • Risperidone Tabs (Age Limit)
  • Sertraline Concentrate Oral Solution 20mg/ml (Age Limit)
  • Thyroid Tabs 15mg, 30mg, 60mg, 90mg, 120mg (Quantity Level Limit)

 

July 2019

Additions:

  • Cefixime Cap 400mg (Quantity Level Limit)
  • Erlotinib Tab 150mg (Prior Authorization Required)
  • Mesalamine DR Cap 400mg (Quantity Level Limit)

Removals:

  • Suprax Cap 400mg (brand)
  • Tarceva Tab 150mg (brand)

 

June 2019

Additions:

  • Docosanol Cream 10% (Quantity Level Limit)
  • Melatonin Tabs 1mg, 3mg, 5mg

Removals:

  • Abreva Cream 10% (brand)

 

May 2019

Additions:

  • Erythromycin Ethylsuccinate Suspension 400mg/5ml
  • Fulphila Injection 6mg/0.6ml (Prior Authorization Required)
  • Nivestym Injection 300mcg, 480mcg (Prior Authorization Required)
  • Sirolimus Solution 1mg/ml
  • Udenyca Injection 6mg/0.6ml (Prior Authorization Required)

Removals:

  • Eryped Suspension (brand) 400mg/5ml
  • Rapamune Solution (brand) 1mg/ml

 

 

April 2019

Other Updates:

  • Antiretroviral Medications (Diagnosis Confirmation Required)

 

March 2019

Additions:

  • Admelog Vial 300 units/3mL
  • Albuterol HFA Inhaler 90mcg – generic Ventolin HFA (Quantity Level Limit)
  • Arthritis Pain Relieving Cream 0.075%
  • Carafate Oral Suspension 1gm/10ml (Age Limit)
  • Mesalamine Suppository 1000mg
  • Toremifene Tab 60mg

Removals:

  • Canasa Suppository 1000mg
  • Fareston Tab 60mg
  • Norethindrone Acetate & Estradiol-FE Tab 1mg-20mcg (24)

Other Updates:

  • Attention Deficit/Hyperactivity Disorder Stimulant Medications (Age Limit, Removed Prior Authorization)
  • Butalbital Containing Products (Quantity Level Limit)
  • Citalopram Oral Solution 10mg/5ml (Age Limit)
  • Dicyclomine Oral Solution 10mg/ml (Age Limit)
  • Escitalopram Oral Solution 5mg/5ml (Age Limit)
  • Famotidine Oral Suspension 40mg/5ml (Age Limit)
  • Lansoprazole Oral Suspension 3mg/ml (Age Limit)
  • Nitrofurantoin Oral Suspension 25mg/5ml (Age Limit)
  • Nortriptyline Oral Solution 10mg/5ml (Age Limit)
  • Omeprazole Oral Suspension 2mg/ml (Age Limit)
  • Oseltamivir Cap 30mg (Removed Age Limit)
  • Oseltamivir Oral Suspension 6mg/ml (Removed Age Limit)
  • Prednisone Oral Solution 5mg/5ml (Age Limit)

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

 

Acamprosate

Actimmune 

Alphanate-Humate 

Antidepressants   NEW 06.08.2020

Atypical Antipsychotics Long-Acting Injectables  Updated 06.08.2020

Atypical Antipsychotics Oral  Updated 06.08.2020

Botulinum Toxins  

Buprenorphine-Naloxone  

Calcitonin Gene-Related Peptide Receptor Antagonists 

CNS Stimulants (ADD/ADHD Medications)  Updated 06.08.2020

Colony Stimulating Factor  

Corlanor  NEW 06.08.2020

Cystic Fibrosis  Updated 06.08.2020

Cytokine and CAM Antagonists  Updated 06.08.2020

Dalfampridine (Ampyra) 

Daliresp 

Daraprim 

DPP-4 Inhibitors

Dupixent  

Egrifta  NEW 06.08.2020

Emflaza  NEW 06.08.2020

Entresto  NEW 06.08.2020

Epidiolex  NEW 06.08.2020

Erythropoiesis Stimulating Agents  

Estradiol Vaginal Cream

Factor IX Agents

Factor VIII Agents 

Feiba

Gonadotropin Releasing Hormone Analogs  

Growth Hormone   

Hemlibra

Hepatitis C   Updated 06.08.2020

Hyaluronic Acid Derivatives  

Hyperlipidemia Medications (Epanova, Lovaza, Vascepa)

IL-5 Antagonists

Increlex  

Injectable Osteoporosis  

Intron A Alferon N 

Janus Associated Kinase Inhibitors  

Jardiance

Juxtapid – Kynamro

Lyrica 

Movantik 

Monoamine Depletors (Austedo, Ingrezza, tetrabenzaine)  NEW 06.08.2020

Multiple Sclerosis Agents   Updated 06.08.2020

Non-Formulary Medication

Novoseven RT

Nuedexta

Obizur

Octreotide

Omega 3 carboxylic acids (Epanova)

Oncology - Afinitor-Afinitor Disperz

Oncology - Capecitabine (Xeloda)

Oncology - Imatinib (Gleevec)

Oncology - Inlyta

Oncology - Nexavar

Oncology - Revlimid

Oncology - Sutent

Oncology -Tarceva

Oncology - Tykerb

Oncology - Votrient

Ondansetron

Onychomycosis tinea 

Opioids Long and Short Acting  

PCSK9 Inhibitors 

Pegasys for hepatitis B

Platelet Inhibitors 

Promacta 

Pulmonary Arterial Hypertension  

Ranexa

Restasis-Xiidra

Rosuvastatin

Sandostatin Analogs

Savella

Somatostatin analogs

Sylatron

Synagis 

Tavalisse

Testosterone

Topical Hyaluronic Acid Derivatives

Wilate-Vonvendi

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 06.08.2020)

 

Acamprosate                                            

Antihyperlipidemics                                                                           

Botulinum Toxins   (effective 04.01.2020)                                    

Buprenorphine                            

Colony Stimulating Factors (effective 04.01.2020)                      

Compound Guideline 

Cytokine and CAM Antagonists (effective 06.08.2020)

Daliresp 

Daraprim    

Diabetic Testing Supplies 

Elmiron               

Generic Substitution  

Growth Hormone  (effective 04.01.2020)

Hemophilia                                                

Hepatitis C (effective 06.08.2020)

Hereditary Angioedema Agents (effective 04.01.2020)                                 

Immune Globulins (effective 04.01.2020)

Injectable Osteoporosis Agents (effective 04.01.2020)          

Interferons (non-Hepatitis C) 

Interleukin-5 Antagonist 

Jardiance 

Lyrica                                             

Movantik 

Multiple Sclerosis Agents (effective 06.08.2020)

Non-Formulary Medication 

Nuedexta 

Off Label Use 

Oncology - Inlyta 

Oncology - Revlimid 

Oncology - Second/Third Generation TKI (Iclusig, Sprycelm Tasigna, Bosulif) 

Oncology - Sutent 

Opioids Long and Short Acting (effective 04.01.2020)

Platelet Inhibitors 

Promacta 

Proton Pump Inhibitors 

Pulmonary Fibrosis Agents 

Quantity Limits 

Ranexa 

Restasis and Xiidra 

Somatostatin Analogs  

Synagis 

Tavalisse 

Testosterone 

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.