Another group or vendor provides the info on the next page. If you don’t want to leave our site, choose the “X” in the upper right corner to close this message. Or choose “Go on” to move forward.
Outpatient medications
Questions about a member’s pharmacy benefits or a specific medication?
For Medicaid:
Contact 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.
For CHIP:
Contact CVS Caremark at 1-800-241-3260, or view a copy of the current CHIP PDL (PDF).
Inpatient medications
Questions about medications a member receives in a provider’s office, hospital or infusion center setting?
Just call us at 1-888-348-2922 (TTY: 711). We’re here for you 24 hours a day, 7 days a week.
Medical pharmaceutical management
Medical pharmaceutical management
Pharmacy coverage updates
We inform our members and prescribing providers of updates once a year, as well as any time we make a change. This information includes:
- A list of code changes determined by BMS and the Aetna® Utilization Management Steering Committee (UMSC)
- This list includes (but is not limited to) changes to prior authorization (PA) requirements.
- A reminder that Aetna Better Health does not manage:
- Prescriptions
- Generic substitution
- Step therapy
- Therapeutic interchange
- Nor do we:
- Administer a closed formulary for medical pharmaceuticals
- Use a formulary for management of medical pharmaceuticals
- Details on a provider’s or member’s right to appeal an adverse determination
- Providers and members can use the appeals process outlined in the Notice of Action letter.
- Details about the pharmacy prior authorization (PA) process, which is the same as requesting PA for medical care and services
- You can review these processes in your provider manual (PDF), in the member materials, or on our prior authorization page.
How we communicate
We notify our members and providers of updates to medical pharmaceutical procedures via:
- Fax
- Our website
- Member newsletters
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 Utilization Management Steering Committee (UMSC). The UMSC is comprised of senior and plan medical directors representing a broad range of specialties such as emergency medicine, behavioral health, pediatrics, surgery, family medicine, internal medicine and pharmacy.
Want the latest medical pharmacy procedures and codes? You can check our Provider Prior Authorization Requirement Search Tool, ProPAT.
