Aetna has implemented a new Prior Authorization policy and process . Please see directions under the Prior Authorization banner.
For Prior Authorization, it will be necessary to download the Texas Standard Prior Authorization Form. The information for clinical edits for covered drugs, Drugs requiring prior authorization, Prior authorization criteria logic, Supporting tables, References, and Publication History (Click Here) which will take you to the Vendor Drug Program’s website. Once there, you will need to select the criteria for the drug you are needing a Prior Authorization. Once the form is completed, fax it to 1-844-275-1084. Please include any supporting medical records that will assist with the review of the prior authorization request. For all requests, allow 24 hours to complete the authorization process.
Aetna Better Health contracts with CVS Caremark to manage the pharmacy network.
To Our Providers: Please click here to initiate an electronic prior authorization (ePA) request
For more information, please refer to the Provider Manual.
Notice to Pharmacies: Mosquito Repellent Benefit - Texas now covers mosquito repellents for the prevention of the Zika virus.
Please note: Beginning Jan 1, 2016 the preferred Glucose meter and Test Strips will be J&J One Touch products.
Pharmacy benefits are coordinated through CVS Caremark.
Aetna Better Health covers prescription medications. Members can get their prescriptions at no cost (Medicaid) or at low copays (CHIP) when:
- Prescriptions are filled at a network pharmacy.
- Prescriptoins are on the preferred drug list (PDL) or formulary.
It is important for providers to know about all other prescriptions members are taking. Also, doctors should ask members about non-prescription medicines, vitamins or herbal supplements they may be taking.
Preferred Drug List (Medicaid only)
You can find out if a medication is on the preferred drug list. Many preferred drugs are available without prior authorization (PA).
The Texas Medicaid preferred drug list is available on the Texas Vendor Drug Program or the Epocrates website. The service is free and doctors have instant access to information about the drugs covered by the Texas formulary on a Palm or Pocket PC handheld device.
Formulary Drug List (Medicaid and CHIP)
The formulary drug list is a list of drugs that are generally covered under the plan as long as they are medically necessary. This list can be found on the Texas Drug Vendor Program. If you want to request a drug to be added to the formulary please contact an your Aetna Better Health of Texas Provider Representative for assistance.
Formulary updates can be found here
Maximum Allowable Cost (MAC) Portal
Providers can access the CVS Caremark MAC Portal.
Aetna Better Health covers certain over-the-counter drugs if they are on the formulary list. Some of these drugs might include specific requirements to be covered. If these requirements are met, Aetna Better Health will cover the drug. Check the list of covered drugs on the Texas Vendor Drug Program.
All prescriptions must be filled at a network pharmacy. Prescriptions filled at other pharmacies will not be covered.
Electronic Prescribing (e-prescribing, or eRx), allows a doctor to electronically send an accurate, error-free and understandable prescription directly to a pharmacy.
Aetna Better Health and CVS Caremark allow the submission of both paper and electronic prescriptions by doctors. Doctors that prescribe medications electronically must do so in accordance with all applicable State and Federal laws.
Mail Order Prescriptions
Doctors can assist members in completing mail order forms if members need a prescription for a maintenance medication. Find answers to frequently asked questions (FAQs) about mail order services
You can also call CVS Caremark Mail Service Pharmacy at 1-855-271-6603 or fax completed mail order form(s) to 1-800-378-0323.
To obtain a Prior Authorization for a medication, doctors can call Aetna Better Health of Texas at:
Medicaid STAR 1-800-248-7767 (Bexar), 1-800-306-8612 (Tarrant)
Medicaid STAR Kids 1-844-STRKIDS (1-844-787-5437)
CHIP or CHIP Perinate 1-866-818-0959 (Bexar), 1-800-245-5380 (Tarrant)
Choose provider by pressing *, Then say authorization and say pharmacy prior authorization.
Or fax an authorization form designed specifically for pharmacy requests. Doctors must download this form Pharmacy - Texas Standard Prior Authorization Request fill out this form and click here to obtain the appropriate drug criteria from the Vendor Drug website. Both forms should be faxed to 1-844-275-1084.
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
72-Hour Emergency Prescription Supply (Medicaid only)
Federal and Texas laws require pharmacies to dispense a 72-hour emergency supply of a prescribed drug when the medication is needed without delay and the prescriber is not available to complete the prior authorization. This applies to non-preferred drugs on the Preferred Drug List and any drug that is affected by a clinical Prior Authorization needing prescriber’s prior approval.
The pharmacy will submit an emergency 72-hour prescription when warranted. This procedure will not be used for routine or continuous overrides.
For further details about the 72-hour emergency supply requests, please refer to the Texas Vendor Drug Program.
Comprehensive Care Program (Medicaid only)
The Medicaid Comprehensive Care Program (CCP) can cover medically necessary drugs and supplies that are not covered by the Vendor Drug Program for members from birth through 20 years of age. Members can call TMHP at 1-800-335-8957 to locate a participating CCP pharmacy provider.
Durable Medical Equipment (DME)
Participating pharmacies are available to provide some Durable Medical Equipment (DME) and medical supplies to Medicaid (STAR) and CHIP plan members. These participating pharmacies are covered by the state of Texas Medicaid (STAR) and CHIP Programs.
Click here for more information about DME benefits and participating pharmacies.
Pharmacy Contact Information
Caremark Pharmacy Help Desk 1-877-874-3317
Texas Vendor Drug Program 1-800-435-4165
Training for Pharmacists and Medical Professionals
CVS Caremark provides training resources for pharmacists and medical professionals from details about drug lists to clinical programs and publications.
See CVS Caremark for more information.
Aetna Better Health Specialty Drug Program is managed through CVS Health Specialty Pharmacy. The Specialty pharmacies fill prescriptions and ship drugs for complex medical conditions, including hepatitis C, multiple sclerosis, hemophilia, rheumatoid arthritis and most cancer drugs. Medications provided through CVS specialty pharmacy include injectable, oral and inhaled drugs.
The Specialty Drug Program provides care management services to your members, including:
- 24 hours a day, seven days a week access to a pharmacist
- Disease-specific education and counseling by the CareTeamTM. The CareTeamTM are clinical professionals who review dosing and medication schedules, identify injection issues, provide education of potential side effects and provide information to help your patient to manage their medical condition.
- Care coordination
- Delivery of Specialty drugs to your patient’s home and/or your office in temperature-controlled packaging with the required supplies, i.e. needles, syringes, and alcohol wipes or patients can be directed to drop off and pick up most of their prescriptions at any CVS Pharmacy location (including those inside Target stores*)
Contact CVS Specialty Pharmacy at 1-800-237-2767 from 7:30 a.m. (EST) to 9:00 p.m. (EST) time, Monday – Friday. CVS Specialty Pharmacy will assist you in filling your patient’s specialty drug. Prior Authorization (PA) still applies to specific specialty drugs. You can check our health plan website to confirm PA requirements on the medications listed below.
Specialty medications can be delivered to the provider’s office, member’s home, or other location as requested.