Prescription drugs

Aetna Better Health of Ohio members who are enrolled with us for both Medicare and Medicaid get prescription drugs that are covered by Medicare as well as drugs that are covered by Medicaid.

As a Medicare beneficiary, you have the right to certain prescription drug benefits. Medicare prescription drug benefits are also known as Part D.

This section provides information about the prescription drug benefits covered by Aetna Better Health of Ohio, including specialty drugs. This section also provides information about coverage limitations that may apply to some covered drugs.  You can also learn about our Medication Therapy Management Program.

Prescription drugs are often an important part of managing a health issue. For your peace of mind, it helps to know that a drug you take is paid for. You can find out by reading our List of Covered Drugs. This is sometimes called a “formulary.” It is a list of drugs we cover and any costs you may have to pay.

Your Aetna Better Health of Ohio List of Covered Drugs is below. If you have any questions about a drug that is not listed, please call Member Services at 1-855-364-0974 (toll-free), 24 hours a day, 7 days a week. TTY 711.

 

Find out if your medicine is covered
A formulary is a list of drugs covered by Aetna Better Health of Ohio. It also is sometimes called a prescription drug list. Aetna Better Health of Ohio consulted with a team of health care providers to develop the formulary. It includes prescription therapies believed to be a necessary part of a quality treatment program.

Aetna Better Health of Ohio generally covers the drugs listed in our formulary as long as the drug is medically necessary. Also, you need to fill the prescription at a pharmacy in the Aetna Better Health of Ohio network. Make sure you follow other plan rules. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.”

Aetna Better Health of Ohio Prescription Drug Search Tool - 2020

Formulary List

Step Therapy Criteria

Contact us for the most recent list of drugs, or to order a paper copy of the formulary at 1-855-364-0974 (toll-free), 24 hours a day, 7 days a week. TTY  711.

Find out where to get your medicine
View your Aetna Better Health of Ohio 2020 pharmacy locator tool.

Contact us if you would like more information about the provider/pharmacy directory at 1-855-364-0974 (toll-free), 24 hours a day, 7 days a week. TTY 711.

For certain kinds of drugs, you can use the plan’s network mail-order services. Generally, the drugs available through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. The drugs that are available through the plan’s mail-order service are marked as “MO” (Available at Mail Order) in our Drug List.

Our plan’s mail-order service requires you to order a 90-day supply.

Download the Prescription Drug Mail-Order OTC Form (English & Español)

To get order forms and information about filling your prescriptions by mail call Aetna Better Health of Ohio Member Services at 1-855-364-0974 (hearing impaired TTY/TDD 711) (24 hours a day, 7 days a week) to request a mail order form or you can register on line with CVS Caremark. Once registered, you will be able to order refills, renew your prescription and check the status of your order.

Ask your doctor to write a new prescription(s) for up to the maximum mail order day supply. Please be advised that our mail order pharmacy will call you to obtain consent before shipping or delivering any prescriptions you do not personally initiate.

Fill out the order form completely, including your member ID#, your doctor's name, medications you are taking and any allergies, illnesses or medical conditions you may have.

Mail the order form and the prescription(s) to:
CVS Caremark
PO Box 2110
Pittsburgh, PA 15230-2110

When you order prescription drugs through the network mail-order pharmacy service, you must order no more than a 90-day supply of the drug. Generally, it takes CVS Caremark up to 21 days to process your order and ship it to you. However, please allow up to 21 days for the initial mail order fill.

Usually a mail-order pharmacy order will get to you in no more than 21 days. If a mail order is delayed by the mail order pharmacy 21 days or more, you will be contacted and told about the delay. If you have not received an order within 21 calendar days of when you sent the order, call CVS Caremark Customer Care at 1-800-552-8159 (TTY 1-800-231-4403) and they will begin processing a replacement order. The order will be quickly sent to you. Calls to this number are free.

Aetna Better Health of Ohio requires you (or your physician) to get prior authorization for some drugs. This means that you need to get approval from Aetna Better Health of Ohio before you fill your prescriptions. If you don’t, Aetna Better Health of Ohio may not cover the drug. Learn more about Prior Authorization Criteria.

Download the Prior Authorization Form

Download the Hospice Exception Form for Medicare Part D plans.


Visit the 2020 online formulary tool or contact us for the most recent list of drugs at 1‑855-364-0974 (toll-free), 24 hours a day, 7 days a week. TTY Relay Ohio 711.

Find out if your medicine is covered
A formulary is a list of drugs covered by Aetna Better Health of Ohio. It also is sometimes called a prescription drug list. Aetna Better Health of Ohio consulted with a team of health care providers to develop the formulary. It includes prescription therapies believed to be a necessary part of a quality treatment program.

Aetna Better Health of Ohio generally covers the drugs listed in our formulary as long as the drug is medically necessary. Also, you need to fill the prescription at a pharmacy in the Aetna Better Health of Ohio network. Make sure you follow other plan rules.

Aetna Better Health of Ohio Prescription Drug Search Tool - 2020

Formulary List

Step Therapy Criteria


Contact us for the most recent list of drugs at 1-855-364-0974 (toll-free), 24 hours a day, 7 days a week. TTY Relay Ohio 711.

Aetna Better Health of Ohio limits the amount of some of the drugs that we cover. For example, Aetna Better Health of Ohio covers up to 60 capsules per 30 days per prescription for Pradaxa. This may be filled in a standard one-month or three-month supply depending how your doctor wrote your prescription. Learn more about the Quantity Limit Criteria.

Visit the 2020 online formulary tool or contact us for the most recent list of drugs at 1‑855-364-0974 (toll-free), 24 hours a day, 7 days a week. TTY Relay Ohio 711.

When you join Aetna Better Health of Ohio and you learn that we do not cover a prescription drug you were taking before you joined our Plan, you may be able to get a temporary fill of up to a 30-day supply of that prescription drug (or less, as prescribed) at a retail pharmacy. This gives you the opportunity to work with your doctor to complete a successful transition to your new coverage year and avoid disruption in your treatment. This is called the Transition of Coverage (TOC) process. If you receive a transition fill for a drug, we will send you a letter explaining that the drug was filled under the transition of coverage process. The letter will explain the action you can take to get approval for the drug or how to switch to another drug on the plan formulary.

Right to Transition Fill

All participants (new and renewing) in a Plan will be equally treated as new participants under the Transition Fill policy at the beginning of the new plan year.

If you are a new participant and are taking a drug that is not on the Aetna Better Health of Ohio formulary, or is subject to a utilization management requirement or limitation (such as step therapy, prior authorization, or a quantity limit), you are entitled to receive up to a 30-day supply of the drug within the first 90-days of your enrollment. This period of time is called your “transition period”. If your prescription is written for less than30-day supply, you can get it refilled until you reach the up to a 30-day supply.

Renewing participants, who are taking a drug that was removed from the formulary or the drug now has anew utilization requirement or limitation at the beginning of the new plan year, also get a “transition period”. You can get up to a 30-day supply of medication during the first 90-days of the new plan year. If your prescription is written for less than a 30-day supply, you can get it refilled until you reach the up to a 30-day supply.

New and existing participants of Aetna Better Health of Ohio may ask for a Coverage Determination and Exception Request by calling Member Services at 1-855-364-0974 (TTY/TDD: 711), 24 hours a day, 7 days a week.

In general, we will determine your right to a 30-day fill at the pharmacy when you go to fill your prescription. In some situations, we will need to get additional information from your doctor before we can determine if you are entitled to a transition to a 30-day fill.

If you live in a Long Term Care facility, and are entitled to a transition supply, we will allow you to refill your prescription until we have provided you with up to a 31-day supply (unless the prescription is written for less) during your transition period.

You may also be eligible to receive a transition fill outside of your 90-day transition period. For example, you may be eligible to receive a temporary supply of a drug if you experience a change in your “level of care” (i.e., if you have returned home from a stay in the hospital with a prescription for a drug that isn’t on the formulary). There are other situations where you may be entitled to receive a temporary supply of a prescription drug. 

It is important that you understand that the transition fill is temporary supply of this drug. Before this supply ends, you should speak to our Plan and/or your physician regarding whether you should change the drug(s) you are currently taking, or request an exception from our Plan to continue coverage of the drug. You, your authorized representative or your provider can ask for an exception request.

Please click here to access a copy of the Coverage Determination and Exception Request form.

Please click here to access a copy of our plan formulary for a complete listing of covered drugs. 

If you have questions about whether you are entitled to a temporary supply of a drug in a particular situation, please call Member Services at 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week.

 

Medication Therapy Management Program

The Aetna Better Health of Ohio medication therapy management program helps you get the greatest health benefit from your medications by:

  • Preventing or reducing drug-related risks
  • Increasing your awareness
  • Supporting good habits

Who qualifies for the program? We will automatically enroll you in the Aetna Better Health of Ohio program at no cost to you if all three conditions apply:

  1. You take eight or more Medicare Part D covered maintenance drugs, and
  2. You have three or more of these long-term health conditions:
  • Asthma
  • Chronic obstructive pulmonary disease
  • Diabetes
  • Depression
  • Osteoporosis
  • Chronic heart failure
  • HIV
  • Cardiovascular disorders such as high blood pressure, high cholesterol or coronary artery disease, and

3. You reach $4,255 in yearly prescription drug costs paid by you and the plan.

Your participation is voluntary, and does not affect your coverage. The program is no cost to you and is open only to those who are invited to participate. The program is not a benefit for all plan members.

 

What services are included in the program?

The program provides you with a:

  • Comprehensive medication review and a
  • Targeted medication review

Comprehensive Medication Review

The review is a one-on-one discussion with a pharmacist, to answer questions and address concerns you have about the medications you take, including:

    • Prescription drugs
    • Over-the-counter (OTC) medicines
    • Herbal therapies
    • Dietary supplements and vitamins

The pharmacist will offer ways to manage your conditions with the medications you take. If more information is needed, the pharmacist may contact your prescribing doctor. The review takes about 30 minutes and is usually offered once each year—if you qualify. At the end of your discussion, the pharmacist will provide you a Personal Medication List with the medications you discussed during your review.

You will also receive a Medication Action Plan. Your plan may include suggestions from the pharmacist for you and your doctor to discuss during your next doctor visit.

Here is a blank copy of the Personal Medication List (English|Spanish) for tracking your prescriptions.
 

Targeted Medication Review

With this review, we mail, fax or call your doctor with suggestions about prescription drugs that may be safer, or work better than your current drugs. As always, your prescribing doctor will decide whether to consider our suggestions. Your prescription drugs will not change unless you and your doctor decide to change them. We may also contact you, by mail or phone, with suggestions about your medications.

How will I know if I qualify for the program?

If you qualify, we will mail you a letter. Also, you may receive a call, inviting you to participate in this one-on-one medication review.

Who will contact me about the review?

You may receive a call from a pharmacy where you recently filled one or more of your prescriptions. You will be given the option to choose an in-person review or a phone review.

You may be contacted by a call center pharmacist to provide your review, and ensure that you have access to the service if you want to participate. These reviews are conducted by phone.

 

Why is a review with a pharmacist important?

Different doctors may write prescriptions for you without knowing all the prescription drugs and/or OTC medications you take. For that reason, a pharmacist will:

  • Discuss how your prescription drugs and OTC medications may affect each other
  • Identify any prescription drugs and OTC medications that may cause side effects and offer suggestions to help
  • Help you get the most benefit from all of your prescription drugs and OTC medications
  • Review opportunities to help you reduce your prescription drug costs

 

How do I benefit from talking with a pharmacist?

  • Discussing your medications can result in real peace of mind knowing that you are taking your prescription drugs and OTC medications safely
  • The pharmacy can look for ways to help you save money on your out-of-pocket prescription drug costs
  • You benefit by having a Personal Medication List and a Medication Action Plan to keep and share with your doctors and health care providers 

How can I get more information about the program?

Please contact us if you would like additional information about our program, or if you do not want to participate after being enrolled in the program. Our number is 1-855-364-0974, 24 hours a day, 7 days a week. (TTY users, call 711)

LTC pharmacies are included in the network.  These pharmacies offer pharmacy services to patients that are housed in a type of group home like a Nursing home or Rehabilitation center.  Generally all LTC pharmacies are in network.  LTC pharmacies will fill prescription orders written by medical staff in the group home and deliver the medication directly to the medical staff who will distribute the medication to the members. Generally, each group home will have one or two LTC pharmacies that supply most of the pharmacy services to all of the members residing in the facility.

To get information about filling your prescriptions at an LTC Pharmacy please call Aetna Better Health of Ohio Member Services at 1-855-364-0974 (TTY 711) 24 hours a day, 7 days a week.

Safe Use of Opioid Pain Medication – Information for Medicare Part D Patients

Prescription opioid pain medications—like oxycodone (OxyContin®), hydrocodone (Vicodin®), morphine, and codeine—can help treat pain after surgery or after an injury, but they carry serious risks, like addiction, overdose, and death. These risks increase with the higher the dose you take, or the longer you use these pain medications, even if you take them as prescribed. Your risks also increase if you take certain other medications, like benzodiazepines (commonly used for anxiety and sleep), or get opioids from many doctors and pharmacies.

Medicare is dedicated to helping you use prescription opioid pain medications more safely, and is introducing new policies for opioid prescriptions in the Medicare Part D prescription drug program beginning in January 2019.

Safety reviews when opioid prescriptions are filled at the pharmacy

Your Medicare drug plan and pharmacist will do safety reviews of your opioid pain medications when you fill a prescription. These reviews are especially important if you have more than one doctor who prescribes these drugs. In some cases, the Medicare drug plan or pharmacist may need to first talk to your doctor.

Your drug plan or pharmacist may do a safety review for:

  • Potentially unsafe opioid amounts.
  • If you take opioids with benzodiazepines like Xanax®, Valium®, and Klonopin®.
  • New opioid use—you may be limited to a 7-day supply or less. This does not apply to you if you already take opioids.

If your pharmacy can’t fill your prescription as written, including the full amount on the prescription, the pharmacist will give you a notice explaining how you or your doctor can contact the plan to ask for a coverage decision. If your health requires it, you can ask the plan for a fast coverage decision. You may also ask your plan for an exception to its rules before you go to the pharmacy, so you’ll know if your plan will cover the medication.

Drug Management Programs (DMPs)

Starting January 1, 2019, some Medicare drug plans (Part D) will have a DMP. If you get opioids from multiple doctors or pharmacies, your plan may talk with your doctors to make sure you need these medications and that you’re using them safely.

If your Medicare drug plan decides your use of prescription opioids and benzodiazepines isn’t safe, the plan may limit your coverage of these drugs. For example, under its DMP your plan may require you to get these medications only from certain doctors or pharmacies to better coordinate your health care.

Before your Medicare drug plan places you in its DMP, it will notify you by letter. You’ll be able to tell the plan which doctors or pharmacies you prefer to use to get your prescription opioids and benzodiazepines. After you’ve had the opportunity to respond, if your plan decides to limit your coverage for these medications, it will send you another letter confirming its decision. You and your doctor can appeal if you disagree with your plan’s decision or think the plan made a mistake. The second letter will tell you how to contact your plan to make an appeal.

Note: The safety reviews and DMPs should not apply to you if you have cancer, get hospice, palliative, or end-of-life care, or if you live in a long-term care facility.

Talk with your doctor

Talk with your doctor about all your pain treatment options including whether taking an opioid medication is right for you. There might be other medications you can take or other things you can do to help manage your pain with less risk. What works best can be different for each patient. Treatment decisions to start, stop or reduce prescription opioids are individualized and should be made by you and your doctor. For more information on safe and effective pain management, visit CDC.gov/drugoverdose/patients.

Additional Resources

Contact your Medicare drug plan for additional information. You can find contact information in your member materials or on your membership card.

Other resources include:

Home infusion pharmacies are included in the network. These pharmacies supply drugs that may need to be given to you by an intravenous route or other non-oral routes, such as intramuscular injections, in your home.

To get information about filling your prescriptions at a Home Infusion Pharmacy please call Aetna Better Health of Ohio Member Services at 1-855-364-0974 (TTY 711) 24 hours a day, 7 days a week.

First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours.

If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber’s supporting statement.

To ask for an exception, call Member Services at 1-855-364-0974 (TTY: 711), 24 hours a day, 7 days a week. A Member Services representative will work with you and your provider to help you ask for an exception.

You can ask Aetna Better Health of Ohio to make an exception to cover a drug that is not on the Drug List.

You can also ask us to change the rules on your drug.

  • For example, Aetna Better Health of Ohio may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more.
  • Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.