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Pharmacy benefits

We manage the pharmacy benefit for medical pharmaceuticals. These are medications for administration in provider offices, hospitals, inpatient facilities or ambulatory care centers. Sometimes medications are also administered by health care professionals in a member’s home. Members don’t have copays for these medications.

The West Virginia Medicaid Fee-For Service program manages the pharmacy benefit for outpatient prescription medications. These are medications that are prescribed by a health care professional and filled at a pharmacy.

Outpatient medications


Questions about a member’s pharmacy benefits or a specific medication?  


Contact the Gainwell Technologies pharmacy help desk at 1-800-847-3859. Or visit the BMS website to see the state's preferred drug list (PDL) and coverage details.


Medical pharmaceuticals


Questions about medications a member receives in a provider’s office, hospital, inpatient facility, ambulatory care center, or in the home?

Call our Utilization Management department at 1-844-835-4930 (TTY: 711).

Medical pharmaceutical management (MPM) and coverage decisions

Medical pharmaceutical management (MPM) and coverage decisions

Our MPM procedures follow the same utilization management processes as requests for medical services using clinical criteria specific to medical pharmaceuticals. Need a copy of the criteria? Call us at 1-844-835-4930 (TTY: 711).

Our MPM procedures don’t include the development of an open or closed formulary or preferred drug list (PDL). However, to promote evidence-based and clinically appropriate drug use, the clinical criteria may include processes for these methods:

  • Pharmaceutical classes
  • Preferred pharmaceuticals
  • Considerations for limiting access to drugs in certain classes
  • Quantity level limits
  • Therapeutic interchange
  • Step therapy
  • Other management methods

The criteria doesn’t include a tiered formulary system that would impact the cost to a member. It also doesn’t include:

  • Generic substitution
  • Automatic substitutions
  • Incentives that apply to the use of certain pharmaceuticals

For medical pharmaceuticals — which are also available in point-of-sale form — we are required to follow the West Virginia Bureau for Medical Services (BMS) preferred drug list (PDL). We're not involved in developing this PDL but refer to it to make decisions within these instances.

Need to request an exception?

We don’t maintain a formulary or PDL, but you may request an exception to the clinical criteria. The exception must be based on medical necessity.

You can make a request in one of two ways:

  • Include the exception request along with your original prior authorization request
  •  Call our Utilization Management department at 1-844-835-4930 (TTY: 711)

In your request, be sure to attach clinical documentation which may include:

  • Evidence of an adverse reaction to a preferred medication
  • Other clinical rationale to support the exception request

An Aetna Better Health pharmacist and/or medical director will review your exception request.

How we communicate 


We notify our members and providers of updates to medical pharmaceutical procedures via:


  • Mail
  • Fax
  • Email
  • Our website
  • Member newsletters
  • Provider workshops


Coverage decisions

Coverage decisions

At least once a year, we review and update medical pharmacy management procedures and medical pharmaceutical codes as determined by our Medicaid Medical Policy Committee (MMPC). The MMPC includes senior and plan medical directors representing a broad range of specialties, such as:

  • Emergency medicine
  • Behavioral health
  • Pediatrics
  • Surgery
  • Family medicine
  • Internal medicine
  • Pharmacy

Want the latest medical pharmacy procedures and codes? You can check our Provider Prior Authorization Requirement Search Tool, ProPAT.

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