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.
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Statewide Preferred Drug List Updates (Medicaid)
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Updates are made regularly to the Statewide Preferred Drug List.
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Supplemental Formulary Updates (Medicaid)
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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
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
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Aetna Better Health Kids Formulary Updates (CHIP)
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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
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Request Forms - Statewide Preferred Drug List (Medicaid)
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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
Analgesics-Non-Opioid Barbiturate Combinations
Analgesics-Opioids Long-Acting
Analgesics-Opioids Short-Acting
Blood Glucose Meters and Test Strips
Erythropoiesis Stimulating Proteins
Interferons Updated 03.20.2020
Monoclonal Antibodies Anti-IL, Anti-IgE
Nuedexta Updated 03.20.2020
Opioid Dependence Treatments, Oral
Opioid Dependence Treatments, Probuphine
Opioid Dependence Treatments, Sublocade
Pituitary Suppressive Agents, LHRH
Somatostatin Analogs Updated 03.20.2020
Stimulants and Related Agents, Provigil, Nuvigil
Zolgensma New 03.20.2020
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Request Forms - CHIP
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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
Atypical Antipsychotics Long-Acting Injectables Updated 04.01.2020
Atypical Antipsychotics Oral Updated 04.01.2020
Botulinum Toxins Updated 04.01.2020
Calcitonin Gene-Related Peptide Receptor Antagonists New 04.01.2020
CNS Stimulants (ADD/ADHD Medications)
Colony Stimulating Factor Updated 04.01.2020
Cystic Fibrosis Updated 04.01.2020
Dalfampridine (Ampyra) Updated 04.01.2020
Dupixent New 04.01.2020
Erythropoiesis Stimulating Agents New 04.01.2020
Gonadotropin Releasing Hormone Analogs New 04.01.2020
Growth Hormone Updated 04.01.2020
Hepatitis C Updated 04.01.2020
Hyaluronic Acid Derivatives New 04.01.2020
Hyperlipidemia Medications (Epanova, Lovaza, Vascepa)
Injectable Osteoporosis New 04.01.2020
Janus Associated Kinase Inhibitors New 04.01.2020
Multiple Sclerosis Agents Updated 04.01.2020
Omega 3 carboxylic acids (Epanova)
Oncology - Afinitor-Afinitor Disperz
Oncology - Capecitabine (Xeloda)
Oncology - Imatinib (Gleevec)
Opioids Long and Short Acting New 04.01.2020
Pulmonary Arterial Hypertension Updated 04.01.2020
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Electronic Prior Authorization (ePA)
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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:
- Visit the CoverMyMeds® website
- Call CoverMyMeds® toll-free at 866-452-5017
- Visit the SureScripts website
- Call SureScripts toll-free at 866-797-3239
Billing Information:
BIN: 610591
PCN: ADV
Group: (Medicaid) RX8813
Group: (CHIP) RX8814
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Prior Authorization Guidelines - Statewide Preferred Drug List (Medicaid)
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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)
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 (PARP approved 02/2019
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 12/2019)
Synagis (PARP approved 12/2019)
Tranexamic Acid (PARP approved 02/2019)
Trial Dose Program (PARP approved 10/2014)
Zolgensma (PARP approved 12/2019)
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Prior Authorization Guidelines - CHIP
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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 04.01.2020)
Botulinum Toxins (effective 04.01.2020)
Colony Stimulating Factors (effective 04.01.2020)
Growth Hormone (effective 04.01.2020)
Hepatitis C (effective 04.01.2020)
Hereditary Angioedema Agents (effective 04.01.2020)
Immune Globulins (effective 04.01.2020)
Injectable Osteoporosis Agents (effective 04.01.2020)
Interferons (non-Hepatitis C)
Multiple Sclerosis Agents (effective 04.01.2020)
Oncology - Inlyta
Oncology - Revlimid
Oncology - Second/Third Generation TKI (Iclusig, Sprycelm Tasigna, Bosulif)
Oncology - Sutent
Opioids Long and Short Acting (effective 04.01.2020)
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Specialty Pharmacy Network
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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
- You or your doctor can visit the web site for an enrollment form: https://www.accuservpharmacy.com/prescribers/rx-forms/
- Phone: 724-978-0110
- Fax: 877-526-8823
Caremark Specialty Pharmacy
- You or your doctor can visit the web site for an enrollment form: https://www.cvsspecialty.com/wps/portal/specialty/healthcare-professionals/enrollment-forms/
- Phone: 877-408-9742 or 1-800-237-2767
- Fax: 1-800-323-2445
Einstein at Center One Pharmacy
- You or your doctor can visit the web site for an enrollment form: https://www.einstein.edu/pharmacy/enrollment
- Phone: 1-877-218-4499
- Fax: 215-827-1934
Elwyn Specialty Care
- You or your doctor can visit the web site for an enrollment form: http://elwynspecialtycare.com/referral-forms/
- Phone: 314-919-4677
- Fax: 610-545-6030
Giant Eagle Pharmacy
- You or your doctor can visit the web site for an enrollment form: https://specialtyrx.gianteagle.com/Providers/EnrollmentForms
- Phone: 888-792-1552 or 440-356-3287
- Fax: 1-877-645-4142
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
- You or your doctor can visit the web site for an enrollment form: https://senderrarx.com/prescribers/forms
- Phone: 1-855-460-7928
- Fax: 888-777-5645
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.
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Aetna Better Health Kids - Step Therapy
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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.
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Tobacco Cessation Resources
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Coming Soon!
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Incontinence supplies
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Pharmacy and Therapeutics (P&T) Committee Minutes (Supplemental Formulary and CHIP)
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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.
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Second Level Pharmacy Provider Appeals
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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:
- Submit the appeal in writing to Aetna Better Health to the address above.
- Include all supporting documentation with the appeal submission:
- Chains/PSAOs
- Documentation of denied Pricing Appeal outcome from the PBM
- Documentation that outreach regarding the denied outcome of appeal has been made to their PSAO or Corporate Headquarters with no resolution
- Independent Pharmacies not affiliated with a PSAO
- Documentation of denied Pricing Appeal outcome from the PBM
- Claim information that includes:
- Pharmacy NCPDP number
- Pharmacy Name
- Name of PSAO (if applicable)
- Prescription number
- NDC
- Drug Name
- Date of Fill
- 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
- Chains/PSAOs
- We will acknowledge a Pharmacy Provider Appeal within five (5) business days after receipt.
- The appeal documentation will be reviewed, and a decision will be rendered within thirty (30) business days after receipt.
- 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.