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.

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.

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

Banks Apothecary

Caremark Specialty Pharmacy

Einstein at Center One Pharmacy

Elwyn Specialty Care

Giant Eagle Pharmacy

Pharmblue LLC

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

Senderra Rx Pharmacy

A personal care plan and ongoing support

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

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

Get extra support for your complex medical condition

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

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

Joining our preferred Specialty Pharmacy network

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

Updates are made regularly to the Statewide Preferred Drug List.

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

 

 

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)
  • 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:

  • Diphenhydramine Elixir 12.5mg/5ml
  • Estradiol Vaginal Cream 0.1mg/gm
  • Felbamate Suspension 600mg/5ml
  • Felbamate Tablet 400mg
  • Felbamate Tablet 600mg
  • Megestrol Suspension 625mg/5ml
  • Omnitrope Injection 5.8mg
  • Udenyca Injection 6mg/0.6ml

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)
  • 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

No Updates

 

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

No Updates

 

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

No Updates

 

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

No Updates

 

April 2021

Additions:

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

Removals:

  • 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 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:

  • Anoro Ellipt Aer 62.5-25
  • Atrovent HFA Aer 17mcg
  • Breo Ellipta Inh 100-25
  • Breo Ellipta Inh 200-25
  • Cefaclor For Susp 125mg/5ml
  • Cefaclor For Susp 250 Mg/5ml
  • Cefaclor For Susp 375 Mg/5ml
  • Clarithromycin Tab ER 24 HR 500mg
  • Combivent Aer 20-100
  • Diazepam Con 5mg/ml
  • Doxycyc Mono Tab 100mg
  • Doxycyc Mono Tab 150mg
  • Doxycyc Mono Tab 50mg
  • Doxycyc Mono Tab 75mg
  • Epogen Inj 10000/ml
  • Epogen Inj 2000/ml
  • Epogen Inj 20000/ml
  • Epogen Inj 3000/ml
  • Epogen Inj 4000/ml
  • Flebogamma Inj 10/200ml
  • Flebogamma Inj 10/200ml
  • Flebogamma Inj Dif 5%
  • Flebogamma Inj Dif 5%
  • Flebogamma Inj Dif 5%
  • Fulphila Inj 6/0.6ml
  • Hyalgan Inj 20mg/2ml
  • Hyalgan Inj 20mg/2ml
  • Hyoscyamine Dro 0.125/ml
  • Janumet Tab 50-1000
  • Janumet Tab 50-500mg
  • Janumet XR Tab 100-1000
  • Janumet XR Tab 50-1000
  • Janumet XR Tab 50-500mg
  • Januvia Tab 100mg
  • Januvia Tab 25mg
  • Januvia Tab 50mg
  • Nivestym Inj 300/0.5
  • Nivestym Inj 300mcg
  • Nivestym Inj 480/0.8
  • Nivestym Inj 480mcg
  • Ofev Cap 100mg
  • Ofev Cap 150mg
  • Verzenio Tab 100mg
  • Verzenio Tab 150mg
  • Verzenio Tab 200mg
  • Verzenio Tab 50mg
  • Victoza Inj 18mg/3ml

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

No Updates

 

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

 

December 2021

Additions:

  • Esomeprazole Tab Delayed Release 20mg
  • Everolimus Tab 10mg (Prior Authorization Required)
  • Mavyret Packet 50-20mg (Prior Authorization Required)

Removals:

  • Afinitor Tab 10mg

Other Updates:

None

Prior authorization for drugs

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  

Botulinum Toxins     

CNS Stimulants (ADD/ADHD Medications)  

Corlanor  

Dalfampridine (Ampyra)  

Egrifta  

Emflaza   

Hepatitis C   

Hyperlipidemia Medications (Epanova, Lovaza, Vascepa)

Monoamine Depletors (Austedo, Ingrezza, tetrabenzaine) 

Omega 3 carboxylic acids (Epanova)

Opioids Long and Short Acting  

Rosuvastatin

Synagis 

Tepezza 

 

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 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)

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 

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

Banks Apothecary

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.