Pharmacy

PLEASE NOTE: Effective September 1, 2022, Aetna Better Health of Pennsylvania MEDICAID, no longer serves MEDICAID therefore, is no longer reviewing new prior authorizations for your patient.

Providers can verify patient’s eligibility by using The PROMISe^TM Eligibility Verification System (EVS) http://promise.dpw.state.pa.us/

Our Aetna Better Health KIDS (CHIP) plan will continue as usual in our 41-county coverage area. Please reference appropriate links below

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.

For information on key pharmacy benefits we offer to our Medicaid members, click here. Select the Pharmacy drop down and select the Pharmacy Benefit Flyer (MA). You will find a pharmacy brochure specific to our Medicaid pharmacy benefits that you can review with patients when in your office.

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.

For information on key pharmacy benefits we offer to our CHIP members, click here. Select the Pharmacy drop down and select the Pharmacy Benefit Flyer (CHIP). You will find a pharmacy brochure specific to our CHIP pharmacy benefits that you can review with patients when in your office.

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.

Specialty Pharmacy Network

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

Banks Apothecary

You or your doctor can visit the web site for an enrollment form: https://banksapothecary.com/forms/
Phone: 215-494-9403
Fax: 215-357-2129

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:

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.

Statewide Preferred Drug List Updates (Medicaid)

Updates are made regularly to the Statewide Preferred Drug List.

Supplemental Formulary Updates (Medicaid)

December 2022

No Updates

November 2022

No Updates

October 2022

No Updates

September 2022

No Updates

August 2022

No Updates

July 2022

No Updates

June 2022

No Updates

May 2022

Additions:

Sodium Chloride Tab 1gm

April 2022

No Updates

March 2022

No Updates

February 2022

Additions:

Dexcom G5 Mobile Receiver Kit (Prior Authorization Required, Quantity Level Limit)
Dexcom G5 Mobile Transmitter Kit (Prior Authorization Required, Quantity Level Limit)
Dexcom G5 Mobile/G4 Platinum Sensor Kit (Prior Authorization Required, Quantity Level Limit)
Dexcom G6 Receiver (Prior Authorization Required, Quantity Level Limit)
Dexcom G6 Sensor (Prior Authorization Required, Quantity Level Limit)
Dexcom G6 Transmitter (Prior Authorization Required, Quantity Level Limit)
Freestyle Libre 14 Day Reader Device (Prior Authorization Required, Quantity Level Limit)
Freestyle Libre 14 Day Sensor (Prior Authorization Required, Quantity Level Limit)
Freestyle Libre 2 Reader Device (Prior Authorization Required, Quantity Level Limit)
Freestyle Libre 2 Sensor (Prior Authorization Required, Quantity Level Limit)
Freestyle Libre Reader Device (Prior Authorization Required, Quantity Level Limit)

Removals:

None

Other Updates:

Diphenhydramine Hcl Liquid 12.5mg/5ml (Added Quantity Level Limit)

January 2022

No Updates

December 2021

No Updates

November 2021

No Updates

October 2021

Removals:

Dermacinrx Ventrixyl Fe Caplet
Santyl Ointment 250Unit/GM

September 2021

No Updates

August 2021

No Updates

July 2021

No Updates

June 2021

No Updates

May 2021

No Updates

April 2021

No Updates

March 2021

No Updates

Aetna Better Health Kids Formulary Updates (CHIP)

December 2022

Additions:

Benzoyl Peroxide Gel 2.5%

Removals:

Iodoquinol-Hc Cream 1-1%

Other Updates:

November 2022

Additions:

Actimmune Inj 2mu/0.5 (Prior Authorization Required)
Cromolyn Sodium Nasal Aerosol Soln 5.2 Mg/Act (4%) (Added Quantity Level Limit)
Dextromethorphan Polistirex Extended Release Susp 30 Mg/5ml (Added Quantity Level Limit)
Dextromethorphan-Phenylephrine-Apap Cap 10-5-325 Mg (Added Quantity Level Limit)
Dimenhydrinate Tab 50 Mg (Added Quantity Level Limit)
Fexofenadine-Pseudoephedrine Tab Er 12hr 60-120 Mg (Added Quantity Level Limit)
Guaifenesin Tab 200 Mg
Guaifenesin Tab 400 Mg
Guaifenesin Tab Er 12hr 1200 Mg
Icosapent Cap 0.5gm (Prior Authorization Required, Quantity Level Limit)
Imbruvica Sus 70mg/Ml (Prior Authorization Required, Quantity Level Limit)
Intron A Inj 10mu (Prior Authorization Required)
Intron A Inj 18mu (Prior Authorization Required)
Intron A Inj 50mu (Prior Authorization Required)
Mineral Oil Heavy
Mineral Oil Light
Omeprazole Cap Delayed Release 10 Mg (Added Quantity Level Limit)
Orkambi Gra 75-94mg (Prior Authorization Required)
Polyethylene Glycol-Propylene Glycol Pf Op Soln 0.4-0.3%
Polyvinyl Alcohol-Povidone Ophth Soln 5-6 Mg/Ml (0.5-0.6%)
Pseudoephedrine Hcl Tab 30 Mg
Pseudoephedrine-Guaifenesin Tab Er 12hr 60-600 Mg
Refresh Dro Op
Sodium Chloride Hypertonic Ophth Oint 5%
Sodium Fluoride Gel 1.1% (0.5% F)
White Petrolatum-Mineral Oil Ophth Ointment

Removals:

Other Updates:

Aprepitant Capsule 125 Mg (Added Quantity Level Limit)
Aprepitant Capsule 40 Mg (Added Quantity Level Limit)
Artificial Sol Tears
Aspirin Sup 300mg
Atropine Sulfate Ophth Oint 1%
Codeine Sulf Tab 15mg (Added Quantity Level Limit and Age Minimum)
Codeine Sulf Tab 60mg (Added Quantity Level Limit and Age Minimum)
Dextromethorphan-Guaifenesin Tab Er 12hr 60-1200 Mg
Feverall Sup 325mg
Hydromorphon Sup 3mg (Added Quantity Level Limit)
Lohist-Dm Syp 5-2-10mg
Lubricant Dro Eye 0.6%
Lubricating Dro 0.5%
Tusnel C Syp (Added Quantity Level Limit and Age Minimum)

October 2022

Additions:

None

Removals:

None

Other Updates:

Lenalidomide Cap 2.5Mg
Lenalidomide Cap 5Mg
Lenalidomide Cap 10Mg
Lenalidomide Cap 15Mg
Lenalidomide Cap 20Mg
Lenalidomide Cap 25Mg
Varenicline Tartrate Tab 0.5Mg X 11 & Tab 1Mg X 42 PA

September 2022

Additions:

Phospho-Trin K500 Tab

Removals:

Hypersal Nebulization Solution 3.5 %

Other Updates:

K-Phos Tab 500 mg (Brand)

August 2022

Additions:

Bicillin L-A Suspension 2400000 Unit/4ml
Calamine Lotion (Quantity Level Limit)
Calamine-Zinc Oxide Lotion 8-8%
Doxycycline Monohydrate Tab 100mg
Eplerenone Tab 25mg
Eplerenone Tab 50 Mg
Fenofibrate Tab 145 Mg
Fenofibrate Tab 48 Mg
Fluocinonide Cream 0.1%
Glucagon Emergency Soln Kit 1mg/Ml (Quantity Level Limit)
Hydrocortisone Acetate Ointment 1% (Quantity Level Limit)
Ivermectin Lotion 0.5% (Quantity Level Limit, Step Therapy)
Metronidazole Gel 1% (Quantity Level Limit, Step Therapy)
Olmesartan Medoxomil Tab 20 Mg (Quantity Level Limit)
Olmesartan Medoxomil Tab 40 Mg (Quantity Level Limit)
Olmesartan Medoxomil Tab 5 Mg (Quantity Level Limit)
Olopatadine Hcl Ophth Soln 0.2% (OTC)
Onetouch Ultra 2 Kit W/ Device
Onetouch Verio Flex System Kit W/ Device
Onetouch Verio Reflect Kit W/ Device
Pataday Solution 0.7% Ophth
Permethrin Liquid 1%
Selenium Sulfide Shampoo 1%
Symjepi Solution Prefilled Syringe 0.15mg/0.3ml (Quantity Level Limit)
Symjepi Solution Prefilled Syringe 0.3 Mg/0.3ml (Quantity Level Limit)
Tetrabenazine Tab 12.5mg (Prior Authorization Required, Quantity Level Limit)
Triamcinolone Acetonide Ointment 0.05% (Quantity Level Limit)
Triprolidine Hcl Drops 0.938mg/Ml
Triprolidine Hcl Liquid 0.625mg/Ml (Pediaclear PD Liquid)
Voriconazole Tab 200mg (Prior Authorization Required)
Voriconazole Tab 50mg (Prior Authorization Required)

Removals:

Other Updates:

Acyclovir Cap 200 Mg (Removed Quantity Level Limit)
Acyclovir Tab 400 Mg (Removed Quantity Level Limit)
Acyclovir Tab 800 Mg (Removed Quantity Level Limit)
Austedo Tab 12mg (Added Quantity Level Limit)
Austedo Tab 6mg (Added Quantity Level Limit)
Austedo Tab 9mg (Added Quantity Level Limit)
Ceftriaxone Sodium For Inj 1 Gm (Changed Quantity Level Limit)
Ceftriaxone Sodium For Inj 2 Gm (Changed Quantity Level Limit)
Ceftriaxone Sodium For Inj 250 Mg (Changed Quantity Level Limit)
Ceftriaxone Sodium For Inj 500 Mg (Changed Quantity Level Limit)
Ezetimibe Tab 10 Mg (Removed Step Therapy)
Glucagon Emergency Kit 1mg Injection (Changed Quantity Level Limit)
Gvoke Hypopen Solution Auto-Injector 0.5mg/0.1ml (Changed Quantity Level Limit)
Gvoke Hypopen Solution Auto-Injector 1mg/0.2ml (Changed Quantity Level Limit)
Gvoke Pfs Solution Prefilled Syringe 0.5mg/0.1ml (Changed Quantity Level Limit)
Gvoke Pfs Solution Prefilled Syringe 1mg/0.2ml (Changed Quantity Level Limit)
Olopatadine Hcl Ophth Soln 0.1% (OTC) (Removed Step Therapy)
Omega-3-Acid Ethyl Esters Cap 1 Gm (Removed Step Therapy)
Valacyclovir Hcl Tab 1gm (Removed Quantity Level Limit)
Valacyclovir Hcl Tab 500 Mg (Removed Quantity Level Limit)

July 2022

Additions:

None

Removals:

None

Other Updates:

None

June 2022

Additions:

Epivir HBV Soln 5mg/ml (Quantity Level Limit)
Gvoke Hypopen 1-Pack 0.5mg/0.1ml (Quantity Level Limit)
Gvoke PFS INJ 1mg/0.2ml (Quantity Level Limit)
Lamivudine Tab 100mg (Quantity Level Limit)
Pregabalin Cap 200mg (Prior Authorization Required, Quantity Level Limit)

Removals:

None

Other Updates:

None

May 2022

Additions:

Ozempic (2mg/Dose) 8mg/3ml (Quantity Level Limit, Step Therapy)
Triumeq PD Tab 60-5-30mg (Prior Authorization Required, Quantity Level Limit)

Removals:

None

Other Updates:

None

April 2022

Additions:

Descovy Tab 120-15mg (Prior Authorization Required, Quantity Level Limit)

Removals:

None

Other Updates:

None

March 2022

Additions:

Brimonidine Tartrate-Timolol Maleate Ophth Soln 0.2-0.5% (Quantity Level Limit, Step Therapy)
Maraviroc Tab 150mg
Maraviroc Tab 300mg
Systane Gel Drop 0.4-0.3%

Removals:

Combigan Ophth Soln 0.2-0.5%
Dry Eye Relief Drops 0.4-0.3%
Selzentry Tab 150mg
Selzentry Tab 300mg

Other Updates:

None

February 2022

Additions:

Dexcom G5 Mobile Receiver Kit (Prior Authorization Required, Quantity Level Limit)
Dexcom G5 Mobile Transmitter Kit (Prior Authorization Required, Quantity Level Limit)
Dexcom G5 Mobile/G4 Platinum Sensor Kit (Prior Authorization Required, Quantity Level Limit)
Dexcom G6 Receiver (Prior Authorization Required, Quantity Level Limit)
Dexcom G6 Sensor (Prior Authorization Required, Quantity Level Limit)
Dexcom G6 Transmitter (Prior Authorization Required, Quantity Level Limit)
Freestyle Libre 14 Day Reader Device (Prior Authorization Required, Quantity Level Limit)
Freestyle Libre 14 Day Sensor (Prior Authorization Required, Quantity Level Limit)
Freestyle Libre 2 Reader Device (Prior Authorization Required, Quantity Level Limit)
Freestyle Libre 2 Sensor (Prior Authorization Required, Quantity Level Limit)
Freestyle Libre Reader Device (Prior Authorization Required, Quantity Level Limit)
Freestyle Libre Sensor System (Prior Authorization Required, Quantity Level Limit)
Levocetirizine Tablet 5mg (Quantity Level Limit)
Naloxone Nasal Liquid 4mg/0.1ml (generic)
Norditropin Flexpro Injection 10mg/1.5ml (Prior Authorization Required)
Norditropin Flexpro Injection 15mg/1.5ml (Prior Authorization Required)
Norditropin Flexpro injection 30mg/3ml (Prior Authorization Required)
Norditropin Flexpro Injection 5mg/1.5ml (Prior Authorization Required)
Ziextenzo (Prior Authorization Required)

Removals:

Other Updates:

Diphenhydramine Hcl Liquid 12.5mg/5ml (Added Quantity Level Limit)
Eliquis DVT/PE Starter Pack Tablet 5mg (Removed Prior Authorization Required)
Eliquis Tablet 2.5mg (Removed Prior Authorization Required)
Eliquis Tablet 5mg (Removed Prior Authorization Required)
Promethazine Hcl Syrup 6.25mg/5ml (Added Quantity Level Limit)
Xarelto 10mg (Removed Prior Authorization Required)
Xarelto 15mg (Removed Prior Authorization Required)
Xarelto 20mg (Removed Prior Authorization Required)
Xarelto Starter Pack 15/20mg (Removed Prior Authorization Required)

January 2022

Additions:

Etravirine Tab 100mg (Prior Authorization Required)
Etravirine Tab 200mg (Prior Authorization Required)
Gvoke Kit Solution 1mg/0.2ml (Quantity Level Limit)

Removals:

Intelence Tab 100mg
Intelence Tab 200mg

Other Updates:

None

December 2021

Additions:

Esomeprazole Tab Delayed Release 20mg
Everolimus Tab 10mg (Prior Authorization Required)
Insulin Glargine-Yfgn Solution Vial 100unit/ml
Insulin Glargine-Yfgn Solution Pen-Injector 100unit/ml
Lopinavir-Ritonavir Tab 100-25mg (Prior Authorization Required)
Lopinavir-Ritonavir Tab 200-25mg (Prior Authorization Required)
Mavyret Packet 50-20mg (Prior Authorization Required)

Removals:

Afinitor Tab 10mg
Kaletra Tab 100-25mg
Kaletra Tab 200-25mg
Semglee Pen-Injector 100unit/ml
Semglee Vial (Solution) 100unit/ml

Other Updates:

None

November 2021

Additions:

None

Removals:

None

Other Updates:

None

October 2021

Additions:

Sunitinib Cap 12.5mg (Prior Authorization Required, Quantity Level Limit)
Sunitinib Cap 25mg (Prior Authorization Required, Quantity Level Limit)
Sunitinib Cap 37.5mg (Prior Authorization Required, Quantity Level Limit)
Sunitinib Cap 50mg (Prior Authorization Required, Quantity Level Limit)

Removals:

Sutent Cap 12.5mg (Brand)
Sutent Cap 25mg (Brand)
Sutent Cap 37.5mg (Brand)
Sutent Cap 50mg (Brand)

Other Updates:

None

September 2021

Additions:

None

Removals:

None

Other Updates:

None

August 2021

Additions:

Baqsimi Powder 3mg/Dose (Quantity Level Limit)
Endari Powder 5gm (Prior Authorization Required)
Inlyta Tab 1mg (Prior Authorization Required, Quantity Level Limit)
Inlyta Tab 5mg (Prior Authorization Required, Quantity Level Limit)
Nayzilam Spray 5mg (Prior Authorization Required, Quantity Level Limit)
Pregabalin Cap 100mg (Prior Authorization Required, Quantity Level Limit)
Pregabalin Cap 150mg (Prior Authorization Required, Quantity Level Limit)
Pregabalin Cap 225mg (Prior Authorization Required, Quantity Level Limit)
Pregabalin Cap 25mg (Prior Authorization Required, Quantity Level Limit)
Pregabalin Cap 300mg (Prior Authorization Required, Quantity Level Limit)
Pregabalin Cap 50mg (Prior Authorization Required, Quantity Level Limit)
Pregabalin Cap 75mg (Prior Authorization Required, Quantity Level Limit)
Prolia Solution (Prior Authorization Required, Quantity Level Limit)
Semglee Inj 100-Unit Pen-Injector
Semglee Inj 100-Unit Vial Solution
Sofosbuvir-Velpatasvir Tab 400-100mg (Prior Authorization Required, Quantity Level Limit)

Removals:

Caffeine Citrate Powder
Ibrance Cap 100mg
Ibrance Cap 125mg
Ibrance Cap 75mg
Lidocaine-Hydrocortisone Acetate Cream 3-0.5%
Methoxsalen Rapid Cap 10mg
Nexavar Tab 200mg

Other Updates:

None

July 2021

Additions:

None

Removals:

None

Other Updates:

None

June 2021

Additions:

None

Removals:

Linzess Cap 72mcg
Linzess Cap 145mcg
Linzess Cap 290mcg

Other Updates:

Trulicity Inj 0.75/0.5 (Added Quantity Level Limit)
Trulicity Inj 1.5/0.5 (Added Quantity Level Limit)
Trulicity Inj 3/0.5 (Added Quantity Level Limit)
Trulicity Inj 4.5/0.5 (Added Quantity Level Limit)

May 2021

Additions:

None

Removals:

None

Other Updates:

None

April 2021

Additions:

Brinzolamide 1% Ophthalmic Suspension (Quantity Level Limit, Step Therapy)
Azopt 1% Ophthalmic Suspension

March 2021

Additions:

Bevespi Aer 9-4.8mcg (Quantity Level Limit)
Cequa Sol 0.09% PF (Prior Authorization Required)
Doxycycl Hyc Cap 100mg
Doxycycl Hyc Cap 50mg
Doxycycl Hyc Tab 100mg
Esbriet Cap 267mg (Prior Authorization Required)
Esbriet Tab 267mg (Prior Authorization Required)
Esbriet Tab 801mg (Prior Authorization Required)
Flutic/Salme Aer 100/50 (Age Level Limit, Quantity Level Limit)
Hizentra Inj 1gm/5ml (Prior Authorization Required)
Hizentra Inj 2gm/10ml (Prior Authorization Required)
Hizentra Inj 2gm/10ml (Prior Authorization Required)
Hizentra Inj 4gm/20ml (Prior Authorization Required)
Hizentra Sol 20% (Prior Authorization Required)
Hizentra Via 10gm/50m (Prior Authorization Required)
Hizentra Via 1gm/5ml (Prior Authorization Required)
Icosapent Cap 1gm (Prior Authorization Required, Quantity Level Limit)
Myleran Tab 2mg
Ocrevus Inj 300/10ml (Prior Authorization Required, Quantity Level Limit)
Pot & Sod Citrates W/ Cit Ac Soln 550-500-334 Mg/5ml
Privigen Inj 40grams (Prior Authorization Required)
Rabeprazole Tab 20 (Quantity Level Limit)
Sodium Citrate & Citric Acid Soln 500-334 Mg/5ml
Trulicity Inj 0.75/0.5 (Step Therapy Required)
Trulicity Inj 1.5/0.5 (Step Therapy Required)
Trulicity Inj 3/0.5 (Step Therapy Required)
Trulicity Inj 4.5/0.5 (Step Therapy Required)
Tukysa Tab 150mg (Prior Authorization Required)
Tukysa Tab 50mg (Prior Authorization Required)
Valtoco Liq 15 Mg (Quantity Level Limit)
Valtoco Liq 20 Mg (Quantity Level Limit)
Valtoco Spr 10mg (Quantity Level Limit)
Valtoco Spr 5mg (Quantity Level Limit)
Visco-3 Inj 25/2.5ml (Prior Authorization Required)

Removals:

Other Updates:

Albuterol Aer HFA (Added Quantity Level Limit)
Arnuity Elpt Inh 100mcg (Added Quantity Level Limit)
Arnuity Elpt Inh 200mcg (Added Quantity Level Limit)
Arnuity Elpt Inh 50mcg (Added Quantity Level Limit)
Azithromycin Sus 100mg/5ml (Added Age Limit)
Azithromycin Sus 200 Mg/5ml (Added Age Limit)
Cefadroxil Sus 250/5 ml (Added Age Limit)
Cefadroxil Sus 500/5 ml (Added Age Limit)
Cefdinir Sus 125/5ml (Added Age Limit)
Cefdinir Sus 250/5ml (Added Age Limit)
Cefpodo Prox Sus 100/5ml (Added Age Limit)
Cefpodo Prox Sus 50mg/5ml (Added Age Limit)
Cefprozil Sus 125/5ml (Added Age Limit)
Cefprozil Sus 250/5ml (Added Age Limit)
Cephalexin Sus 125/5ml (Added Age Limit)
Cephalexin Sus 250/5ml (Added Age Limit)
Clarithromycin Sus 125mg/5ml (Added Age Limit)
Clarithromycin Sus 250mg/5ml (Added Age Limit)
Extavia Inj 0.3mg (Added Quantity Level Limit)
Gilenya Cap 0.5mg (Added Quantity Level Limit)
Glatiramer Inj 20mg/ml (Added Quantity Level Limit)
Glatiramer Inj 40mg/ml (Added Quantity Level Limit)
Juluca Tab 50-25mg (Added Prior Authorization)
Levalbuterol Aer 45/Act (Added Quantity Level Limit)
Levofloxacin Sol 25mg/ml (Added Age Limit)
Neomycin-Polymyxin-Dexamethasone Ophth Oint 0.1% (Added Quantity Level Limit)
Ondansetron Tablet Dispersible 4mg Oral (Added Quantity Level Limit)
Ondansetron Tablet Dispersible 8mg Oral (Added Quantity Level Limit)
Phenylephrine HCl Ophth Soln 2.5% (Added Quantity Level Limit)
Rebif Inj 22/0.5 (Added Quantity Level Limit)
Rebif Inj 44/0.5 (Added Quantity Level Limit)
Rebif Rebido Inj 22/0.5 (Added Quantity Level Limit)
Rebif Rebido Inj 44/0.5 (Added Quantity Level Limit)
Rebif Rebido Inj Titratn (Added Quantity Level Limit)
Rebif Titrtn Inj Pack (Added Quantity Level Limit)
Santyl Oin 250 Unit/gm (Added Quantity Level Limit)

February 2021

Additions:

None

Removals:

None

Other Updates:

None

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:

Other Updates:

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:

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)

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)

February 2019

Additions:

Arnuity Ellipta Inhaler
Eligard Kit 7.5mg, 22.5mg, 30mg, 45mg (Prior Authorization Required)
Flebogamma IV Solution 5gm/50ml, 10gm/100ml, 20gm/200ml (Prior Authorization Required)
Immune Globulin IV Solution 1gm/10ml, 2.5gm/25ml, 5gm/50ml, 10gm/100ml, 20gm/200ml, 30gm/300ml, 40gm/400ml (Prior Authorization Required)
Leuprolide Acetate Kit 1mg/0.2ml (Prior Authorization Required)
Ozempic Injection (Quantity Level Limit, Step Therapy Required)
Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 27-0.8mg (Quantity Level Limit)
Prenatal Vitamin with Iron Carbonyl-Folic Acid Tab 29-1mg (Quantity Level Limit)
Prenatal Vitamin with Minerals-Ferrous Fumarate-Folic Acid-DHA Pack 28-0.8-200mg (Quantity Level Limit)
Prenatal Vitamin without Vit A with Ferrous Fumarate-Folic Acid Chewable Tab 29-1mg (Quantity Level Limit)
Prenatal Vitamin without Vit A with Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid Cap 20-20-1.25mg (Quantity Level Limit)
Prenatal Vitamin without Vit A with Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid Cap 130-92.4-1mg (Quantity Level Limit)
Segluromet Tabs (Quantity Level Limit, Step Therapy Required)
Steglatro Tabs (Quantity Level Limit, Step Therapy Required)
Victoza Injection (Quantity Level Limit, Step Therapy Required)

Removals:

Alprazolam Orally Disintegrating Tabs
Cleocin Vaginal Ovule 100mg
Clorazepate Dipotassium Tabs
Condylox Gel 0.5%
Cortifoam Rectal Aerosol
Cuprimine Cap 250mg
Dihydroergotamine Mesylate Nasal Spray 4mg/ml
Dulera Inhaler
Elidel Cream 1%
Ergotamine SL Tab 2mg
Ergotamine-Caffeine Suppository 2-100mg
Ergotamine-Caffeine Tab 1-100mg
Flovent Diskus
Humalog Pens/Cartridges
Humalog Vials
Invokamet Tabs
Invokana Tabs
Levonorgestrel-Ethinyl Estradiol Tab 0.15-0.03mg (84) & Ethinyl Estradiol Tab 0.01mg (7)
Lidocaine-Hydrocortisone Rectal Kit 20x7gm
Lidocaine-Hydrocortisone Rectal Kit 3-1%
Meprobamate Tabs
Miconazole 3 Suppository 200mg
Nitro-Bid Cream Packets 2%
Novolog Pens/Cartridges
Novolog Vials
Plan B Tab (Brand Only)
Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 65-1mg
Prenatal Vitamin with Ferrous Fumarate-L Methylfolate-Folic Acid Tab 27-0.6-0.4mg
Prenatal Vitamin with Iron Polysaccharide Complex-Folic Acid Chew Tab 29-1mg
Prenatal Vitamin with Iron Polysaccharide Complex-L Methylfolate-Folic Acid Chew Tab 29-0.6-0.4mg
Prenatal Vitamin with Minerals with Iron Poly Saccharide Complex-Folic Acid-DHA Cap 29-1-200mg
Prenatal Vitamin with Minerals with Iron Poly Saccharide Complex-Folic Acid-DHA Pack 1mg & 250mg
Prenatal Vitamin without Vit A with Ferrous Asparto Glyc-L Methylfolate-Folic Acid- DHA Cap 10-0.6-0.4-200mg
Prenatal Vitamin without Vit A with Ferrous Asparto Glyc-L Methylfolate-Folic Acid- DHA Cap 18-0.6-0.4-300mg
Prenatal Vitamin without Vit A with Ferrous Fumarate-DSS-Folic Acid-DHA Cap 27-1.25-300mg
Prenatal Vitamin without Vit A with Ferrous Fumarate-L Methylfolate-Folic Acid-DHA Cap 27-0.6-0.4-300mg
Pulmicort Flexhaler
Qvar Inhaler
Relenza Diskhaler
Synjardy Tabs
Terconazole Vaginal Suppository 80mg
Thalomid Caps
Triazolam Caps
Trimethobenzamide Cap 300mg
Trulicity Injection

Other Updates:

January 2019

No Changes

December 2018

Additions:

Itraconazole Solution 10mg/ml
Nivestym Injection 300mcg, 480mcg (Prior Authorization Required)

Removals:

Gleostine Caps 10mg, 40mg, 100mg
Mometasone Nasal Spray
Nasonex Nasal Spray
Sporanox Solution 10mg/ml

November 2018

Additions:

Albendazole Tab 200mg (Step Therapy Required)

Removals:

Albenza Tab 200mg

October 2018

Additions:

Admelog Vial
Loratadine Chewable Tab 5mg (Quantity Level Limit)
Prasugrel Tabs (Quantity Level Limit)
Tadalafil Tab 20mg (Step Therapy, Quantity Level Limit)
Tazarotene Cream 0.1% (Quantity Level Limit)
Tymlos Pen (Prior Authorizations Required, Quantity Level Limit)
Valganciclovir Tab 450mg (Quantity Level Limit)

Removals:

Adcirca Tab 20mg

Other Updates:

Ondansetron Tabs 4mg, 8mg (Quantity Level Limit)
Tizanidine Tabs 2mg, 4mg (Quantity Level Limit)

September 2018

Additions:

Colesevelam HCL Packet 3.75gm
Diclofenac Gel 1% (Quantity Level Limit)
Humira Pen CD/UC/HS Starter Kit 80mg/0.8ml (Prior Authorization Required, Quantity Level Limit)
Humira Pen PS/UV Starter Kit 80mg/0.8ml and 40mg/0.4ml (Prior Authorization Required, Quantity Level Limit)
Hydroxyprogesterone Caproate Injection 250mg/ml (Prior Authorization Required)
Omega 3 Ethyl Esters Acid 1gm Cap (Step Therapy, Quantity Level Limit)
Sevelamer Tab 800mg (Step Therapy)
Symtuza Tab (Quantity Level Limit)
Telmisartan Tab 20mg, 40mg, 80mg (Quantity Level Limit)
Tolterodine ER Cap 2mg, 4mg (Step Therapy, Quantity Level Limit)
Vemlidy Tab 25mg (Quantity Level Limit)
Verzenio Tabs 50mg, 100mg, 150mg, 200mg (Prior Authorization Required, Quantity Level Limit)

Removals:

Amlodipine-Valsartan-Hydrochlorothiazide Tabs
Betaxolol Tabs
Calcitriol Solution
Captopril Tabs
Captopril-Hydrochlorothiazide Tabs
Chlorpropramide Tabs
Climara Pro Patch Weekly
Desipramine Tabs
Diltiazem CD Cap 360mg
Femring
Fenofibrate Tab 48mg, 145mg
Fenofibric DR Caps
Fenoprofen Tab 600mg
Lidocaine Cream 3%
Makena Injection 250mg/ml
Marplan Tab 10mg
Meclofenamate Sodium Caps
Methyltestosterone Cap 10mg
Nadolol Tabs
Nisoldipine ER Tabs
Ondansetron Solution
Oxaprozin Tab 600mg
Pindolol Tabs
Pioglitazone-Glimepiride Tabs
Pioglitazone-Metformin Tabs
Potassium-Sodium Citrates & Citric Acid Solution
Premarin Tabs
Premphase Tabs
Prempro Tabs
Protriptyline Tabs
Tolazamide Tabs
Tolbutamide Tab 500mg
Tranylcypromine Tab 10mg
Verapamil ER 24hr Cap 300mg

Other Updates:

Amlodipine Tab 2.5mg, 5mg (Quantity Level Limit)
Baraclude Solution (Quantity Level Limit)
Benazepril Tab 5mg, 10mg, 20mg (Quantity Level Limit)
Benzonatate Caps 100mg, 200mg (Age Limit, Quantity Level Limit)
Clonidine Patches (Step Therapy)
Diazepam Rectal Gel 2.5mg, 10mg, 20mg (Quantity Level Limit)
Diltiazem CD Cap 180mg (Quantity Level Limit)
Diltiazem ER Beads Cap 180mg (Quantity Level Limit)
Diltiazem ER Cap 180mg (Quantity Level Limit)
Elmiron Cap (Prior Authorization Required)
Enalapril Tabs 2.5mg, 5mg, 10mg (Quantity Level Limit)
Estradiol Vaginal Cream 0.01% (Prior Authorization Required)
Estring Vaginal Ring 2mg (Quantity Level Limit)
Flunisolide Nasal Solution 0.025% (Quantity Level Limit)
Fosinopril Tabs 10mg, 20mg (Quantity Level Limit)
Gabapentin Tabs (Cumulative Maximum Dose)
Griseofulvin Suspension (Step Therapy)
Griseofulvin Microsize Tabs (Step Therapy)
Griseofulvin Ultramicrosize Tabs (Step Therapy)
Hydrocodone-Homatropine Syrup (Age Limit, Quantity Level Limit)
Hydrocodone-Homatropine Tabs (Age Limit, Quantity Level Limit)
Lidocaine Ointment 5% (Prior Authorization Required)
Lisinopril Tabs 2.5mg, 5mg, 10mg, 20mg, 30mg (Quantity Level Limit)
Losartan Potassium Tabs 25mg, 50mg (Quantity Level Limit)
Mometasone Furoate Nasal Suspension 50mcg/actuation (Quantity Level Limit)
Oxybutynin ER Tab 15mg (Quantity Level Limit)
Oxybutynin IR Tab 5mg (Quantity Level Limit)
Oxybutynin Syrup (Quantity Level Limit)
Propranolol ER Cap 80mg (Quantity Level Limit)
Quinapril Tabs 5mg, 10mg, 20mg (Quantity Level Limit)
Ramipril Caps 1.25mg, 2.5mg, 5mg (Quantity Level Limit)
Tenofovir Tab 300mg (Quantity Level Limit)
Tolterodine Tabs 1mg, 2mg (Step Therapy)
Trospium ER Cap 60mg (Step Therapy)
Trospium IR Tab 20mg (Step Therapy)

August 2018

Additions:

Retacrit Injection (Prior Authorization Required)
Cimduo Tabs (Quantity Level Limit)

Other Updates:

Loratadine Tab 10mg (Added Quantity Level Limit)
Loratadine Orally Disintegrating Tab 10mg (Added Quantity Level Limit)

July 2018

Additions:

Baclofen Tab 5mg (Quantity Level Limit)
Diphenhydramine Liquid 6.25mg/ml
Norvir Powder Packets 100mg
Pediatric Multiple Vitamins with Iron Drops 11mg/ml
Phytonadione Tab 5mg
Zenpep Cap 15,000 Units
Zenpep Cap 3000 Units

Removals:

Mephyton Tab 5mg

June 2018

Additions:

Humira Pediatric Crohn’s Prefilled Syringe Kit 80mg/0.8ml and 40mg/0.4ml (Prior Authorization Required, Quantity Level Limit)
Humira Pediatric Crohn’s Prefilled Syringe Kit 80mg/0.8ml (Prior Authorization Required, Quantity Level Limit)
Humira Pen-Injector Kit 40mg/0.4ml (Prior Authorization Required, Quantity Level Limit)
Humira Prefilled Syringe Kit 10mg/0.1ml (Prior Authorization Required, Quantity Level Limit)
Humira Prefilled Syringe Kit 20mg/0.2ml (Prior Authorization Required, Quantity Level Limit)
Humira Prefilled Syringe Kit 40mg/0.4ml (Prior Authorization Required, Quantity Level Limit)
Lansoprazole ODT
Praziquantel Tab 600mg (Prior Authorization Required)
Symfi Tab (Quantity Level Limit)
Tasigna Cap 50mg (Prior Authorization Required, Quantity Level Limit)
Zenpep Cap 10,000 Units

Removals:

Biltricide Tab 600mg
Fluorouracil Cream 1%
Pramoxine-HC-Chloroxylenol OTIC solution
Prevacid ODT

Other Updates:

Flunisolide Nasal Spray (Removed Step Therapy)
Fluticasone Nasal Spray (Removed Step Therapy)
Lansoprazole ODT (Removed Prior Auth)
Levonorgestrel Tab 1.5mg (Removed Quantity Level Limit)
Mometasone Nasal Spray (Removed Step Therapy)

May 2018

Additions:

Colchicine Cap 0.6mg (Quantity Level Limit)
Firvanq Sol
Imbruvica Cap 70mg (Quantity Level Limit)
Imbruvica Tab 420mg (Quantity Level Limit)
Imbruvica Tab 560mg (Quantity Level Limit)
Jardiance Tab (Quantity Level Limit, Step Therapy Required)
Refresh Tear Drop 0.5%
Ritonavir 100mg tab
Symfi Lo tab (Quantity Level Limit)
Synjardi Tab (Quantity Level Limit, Step Therapy Required)
Synjardi XR 10mg/1000mg (Quantity Level Limit, Step Therapy Required)
Synjardi XR 12.5mg/1000mg (Quantity Level Limit, Step Therapy Required)
Synjardi XR 25mg/1000mg (Quantity Level Limit, Step Therapy Required)
Synjardi XR 5mg/1000mg (Quantity Level Limit, Step Therapy Required)
Virt-PN DHA tab
Virt-PN tab

Removals:

Other Updates:

Rosuvastatin Tab (Removed Prior Authorization, Added Step Therapy)

April 2018

Additions:

Biktarvy (Quantity Level Limit)

March 2018

Additions:

Armodafinil tablets (Prior Authorization Required, Quantity Level Limit)
Avonex (Prior Authorization Required, Quantity Level Limit)
Betaxolol 0.5% soln (Quantity Level Limit)
Brinzolamide (Quantity Level Limit)
Ciprofloxacin 250mg/5mlsuspension (Quantity Level Limit)
Combigan (Step Therapy Required)
Levobunolol 0.5% soln (Quantity Level Limit)
Metipranolol 0.3% soln (Quantity Level Limit)
Sprycel (Prior Authorization Required, Quantity Level Limit)

Removals:

Betoptic-S suspension 0.25%
Brimonidine 0.15%
Brompheniramine Chew
Cefaclor ER tablets
Cefixime suspension
Cephalexin tablets
Ciloxan ointment
Ciprofloxacin ER tablets
Fluoprolex Cream 1%
Fluorabon Drops
FML Forte 0.25%
Gatifloxacin solution
Homotropine Solution 5% Ophthalmic Drops
Jentadueto
Jentadueto XR
Modafinil tablets
Morphine ER capsules
Moxifloxacin
Nature-Throid
Neomycin/Polymyxin/HC drops
Non-BD diabetic supplies
Ofloxacin
Oxycodone 20mg/ml concentrated soln
Oxycodone 5mg capsules
Oxymorphone
Oxymorphone IR
Pred Mild 0.12%
Silver Nitrate Applicator
Sodium Fluoride Tablets
Suprax chew tablets
TobraDex ointment
Tobramycin/Dexamethasone drops
Tobrex ointment
Tradjenta

Other Updates:

Carteolol 1% soln (Added Quantity Level Limit)
Timolol gel 0.25% & 0.5% (Added Step Therapy)

February 2018

Additions:

Abilify Maintena (Prior Authorization Required)
BD Pen Needles
Betamethasone Dipropionate 0.05% (Quantity Level Limit)
Betamethasone Dipropionate Aug 0.05% lotion, gel & ointment (Quantity Level Limit)
Clobetasol 0.05% gel & ointment (Quantity Level Limit)
Clobetasol 0.05% solution (Quantity Level Limit)
Clobetasol emol 0.05% cream (Quantity Level Limit)
Duloxetine 20mg, 30mg (Quantity Level Limit)
Duloxetine 40mg DR (Quantity Level Limit)
Duloxetine 60mg (Quantity Level Limit)
Eliquis (Prior Authorization Required)
Fluociononide 0.05% gel & ointment (Quantity Level Limit)
Halobetasol 0.05% ointment & cream (Quantity Level Limit)
Invega Sustenna (Prior Authorization Required)
Invega Trinza (Prior Authorization Required)
Janumet (Step Therapy Required)
Janumet XR (Step Therapy Required)
Januvia (Step Therapy Required)
Naproxen 125mg/5ml (Step Therapy Required)
Opsumit (Prior Authorization Required, Quantity Level Limit)
Risperdal Consta (Prior Authorization Required)

Removals:

Albuterol 2mg & 4mg tab
Albuterol ER 4mg & 8mg tab
Amcinonide 0.1% cream & lotion
Capex Shampoo 0.01%
Clobetasol 0.05% lotion & shampoo
Clobetasol Aer 0.05% foam & emolient
Desonide 0.05% cream, lotion, &ointment
Desoximetasone 0.05% cream, gel, & ointment
Desoximetasone 0.25% cream & ointment
Diflorasone 0.05% cream & ointment
Fluocin Body & Scalp Oil 0.01%
Fluocinonide 0.05% Lotion
Fluocinonide 0.1% Cream
Fluticasone 0.05% Lotion
Fondaparinux
Fragmin
HC Butyrate 0.1% cream & ointment
HC Valerate 0.2% cream & ointment
Hydrocort sol but
Pramosone-HC cream 1-1%
Prednicarbt 0.1% cream
Terbutaline 2.5mg & 5mg tab
TobraDex ST suspension
Trianex 0.05% oint
Triderm cream 0.1% (select NDC #’s only)
Vancomycin Capsule 125mg & 250mg

Other Updates:

Brimonidine 0.2% (Changed Quantity Level Limit)
Timolol 0.25% & 0.5% sol (Changed Quantity Level Limit)

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Pharmacy Benefit Brochure (CHIP)

Request Forms - CHIP

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

CNS Stimulants (ADD/ADHD Medications)

Corlanor

Egrifta

Hepatitis C

Monoamine Depletors (Austedo, Ingrezza, tetrabenzaine)

Opioids Long and Short Acting

Synagis

Tepezza

Electronic Prior Authorization (ePA)

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

Prior Authorization Guidelines - Statewide Preferred Drug List (Medicaid)

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 9/2021)

Anthelmintics (PARP approved 11/2020)

Continuous Glucose Monitoring (PARP approved 05/2020)

Compound Guideline (PARP approved 10/2020)

Corlanor (PARP approved 11/2020)

Cystic Fibrosis (PARP approved 08/2020)

Daraprim (PARP approved 06/2018)

Egrifta (PARP approved 09/2021)

Elmiron (PARP approved 09/2021)

Gene Based Therapy for Duchenne Muscular Dystrophy (PARP approved 09/2021)

Generic Substitution (PARP approved 12/2019)

HP Acthar (PARP approved 09/2020)

Interferons (non-Hepatitis C) (PARP approved 08/2021)

IVIG Products (PARP approved 10/2020)

L-Methylfolate Products (PARP approved 09/2020)

Lucemyra (PARP approved 02/2019)

Multaq (PARP approved 11/2020)

Non-Formulary Medication (PARP approved 09/2021)

Nuedexta (PARP approved 10/2020)

Off Label Use (PARP approved 10/2020)

Oxbryta (PARP approved 08/2020)

Quantity Limits (PARP approved 09/2021)

Sensipar (PARP approved 09/2021)

Somatostatin Analogs (PARP approved 10/2020)

Spinraza (PARP approved 09/2021)

Synagis (PARP approved 09/2020)

Tranexamic Acid (PARP approved 11/2020)

Trial Dose Program (PARP approved 10/2014)

Zolgensma (PARP approved 09/2020)

Prior Authorization Guidelines - CHIP

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

Antihyperlipidemics

Botulinum Toxins

Colony Stimulating Factors

Cytokine and CAM Antagonists

Endari

Growth Hormone

Hepatitis C

Hereditary Angioedema Agents

Immune Globulins

Injectable Osteoporosis Agents

Multiple Sclerosis Agents

Nayzilam

Opioids Long and Short Acting

Trial Dose Program

Specialty Pharmacy Network

Careful handling and quick delivery for specialty drugs

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

Banks Apothecary

You or your doctor can visit the web site for an enrollment form: https://banksapothecary.com/forms/
Phone: (215) 494-9403
Fax: (215) 357-2129

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

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:

Joining our preferred Specialty Pharmacy network

Specialty locations

Aetna Better Health Kids - Step Therapy

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.

Tobacco Cessation Resources

Coming Soon!

Incontinence supplies

Incontinence coverage and supplies

Pharmacy and Therapeutics (P&T) Committee Minutes (Supplemental Formulary and CHIP)

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.

Second Level Pharmacy Provider Appeals

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:
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
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.

Pharmacy

Formulary/Preferred Drug Lists

Medicaid Member Preferred Drug List

Aetna Better Health Kids Preferred Drug List

Prior authorization for drugs

Aetna's Custom Prior Authorization Guidelines

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