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).  DHS also has a search tool.

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.


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.


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.

Updates are made regularly to the Statewide Preferred Drug List.

Medicaid Supplemental Formulary Updates

Formulary changes include the following:

  • Addition/removal of a drug from the formulary
  • Addition/removal of quantity level limits
  • Addition/removal of prior authorization requirements


February 2020

No Updates


January 2020


  • Aspirin EC Tabs 81mg, 325mg
  • Aspirin Tabs 81mg, 325mg
  • BD Pen Needles
  • Lancets, Lancet Kits, Lancet Devices
  • Tums Chewable Tabs 500mg, 750mg, 1000mg (Brand Name)


  • Hydrocortisone Rectal Cream 1%
  • Omega-3 Fatty Acids Cap 1400mg


February 2020


  • Bimatoprost Ophthalmic Solution 0.03% (Step Therapy Required)
  • Ethinyl Estradiol – Etonogestrel Ring 0.015mg-0.12mg (Quantity Level Limit)
  • Everolimus Tabs 2.5mg, 5mg, 7mg (Prior Authorization Required)


  • Afinitor Tab 2.5mg, 5mg, 7.5mg (Brand)
  • Alprazolam Concentrate Solution 1mg/ml
  • Chlorothiazide Tabs
  • Demeclocycline Tabs
  • Doxycycline Monohydrate Tab 150mg
  • First-Vanco Solution 25mg/ml, 50mg/ml
  • Homatropine Ophthalmic Solution 5%
  • Kyleena IUD
  • Methylclothiazide Tab 5mg
  • Mirena IUD
  • Nausea Relief Liquid
  • Nizatidine Solution 15mg/ml
  • Nuvaring (Brand)
  • Phospholine Ophthalmic Solution 0.125%
  • Propantheline Cap 15mg
  • Rabeprazole EC Cap 20mg
  • Ranitidine Caps 150mg, 300mg
  • Skyla IUD

Other Updates:

  • Atropine Ophthalmic Ointment 1% (Quantity Level Limit)
  • Atropine Ophthalmic Solution 1% (Quantity Level Limit)
  • Buspirone Tabs 5mg, 7.5mg, 10mg, 15mg (Age Limit)
  • Combigan Ophthalmic Solution 0.5/0.5% (Quantity Level Limit)
  • Diazepam Concentrate 5mg/ml (Quantity Level Limit)
  • Diazepam Oral Solution (Quantity Level Limit)
  • Diazepam Tabs 2mg, 5mg, 10mg (Quantity Level Limit)
  • Divalproex ER Tab 250mg, 500mg (Prior Authorization Required)
  • Dorzolamide-Timolol Ophthalmic Solution 22.3-6.8% (Quantity Level Limit)
  • Doxycycline Monohydrate Suspension 25mg/5ml (Age Limit)
  • Granisetron Tab 1mg (Step Therapy Required)
  • Hydroxyzine Pamoate Caps 25mg, 50mg, 100mg (Quantity Level Limit)
  • Hydroxyzine Syrup 10mg/5ml (Quantity Level Limit)
  • Hydroxyzine Tab 50mg (Quantity Level Limit)
  • Levofloxacin Ophthalmic Solution 0.5% (Quantity Level Limit)
  • Lorazepam Concentrate 2mg/ml (Age Limit, Quantity Level Limit)
  • Memantine Tabs 5mg, 10mg (Quantity Level Limit)
  • Methazolamide Tabs 25mg, 50mg (Step Therapy Required)
  • Natacyn Ophthalmic Suspension 5% (Quantity Level Limit)
  • Tazarotene Cream 1% (Step Therapy Required)
  • Timolol Ophthalmic Gel Solution 0.25%, 0.5% (Quantity Level Limit)
  • Trifluridine Ophthalmic Solution 1% (Quantity Level Limit)


January 2020


  • Buprenorphine-Naloxone Films 2-0.5mg, 4-1mg, 8-2mg, 12-3mg (Quantity Level Limit)


  • Ventolin HFA Inhaler (brand name)


December 2019


  • PreNata Chewable Tab 29-1mg


November 2019

No Updates


October 2019

Other Updates:

  • Cetirizine Solution 1mg/ml (Quantity Level Limit)


September 2019


  • Ambrisentan Tabs 5mg, 10mg (Prior Authorization Required, Quantity Level Limit)
  • Bosentan Tabs 62.5mg, 125mg (Prior Authorization Required, Quantity Level Limit)
  • Febuxostat Tabs 40mg, 80mg (Step Therapy Required)
  • Ramelteon Tab 8mg (Step Therapy Required, Quantity Level Limit)
  • Ribavirin Tab/Cap 200mg (Step Therapy Required)


  • Letairis Tabs 5mg, 10mg (Brand)
  • Rozerem Tab 8mg (Brand)
  • Tracleer Tabs 62.5mg, 125mg (Brand)
  • Uloric Tabs 40mg, 80mg (Brand)


August 2019


  • Aquadeks Drops
  • Butenafine Cream 1% (OTC)
  • Lidocaine Patch 4% (Quantity Level Limit)
  • Thyroid Tabs 180mg, 240mg, 300mg (Quantity Level Limit)


  • Ciclopirox Gel 0.77%
  • Clotrimazole w/ Betamethasone Lotion 1-0.05%
  • Colestipol Granules 5gm
  • Epinastine Ophthalmic Solution 0.05%
  • Fluphenazine Elixir 2.5mg/5ml
  • Fluphenazine Injection 2.5mg/ml
  • Lindane Shampoo 1%
  • Moexipril Tabs 7.5mg, 15mg
  • Nitroglycerin Cap 2.5mg
  • Olopatadine Ophthalmic Solution 0.2%
  • Quinidine Gluconate CR Tab 324mg
  • Thyroid Tab 130mg

Other Updates:

  • Azelastine Ophthalmic Solution 0.05% (Quantity Level Limit)
  • Ciclopirox Cream 0.77% (Step Therapy Required)
  • Ciclopirox Shampoo 1% (Step Therapy Required)
  • Ciclopirox Suspension 0.77% (Step Therapy Required)
  • Fluocinolone Cream 0.025% (Quantity Level Limit)
  • Fluocinolone Ointment 0.025% (Quantity Level Limit)
  • Lidocaine Cream 4% (Quantity Level Limit)
  • Lidocaine Gel 2% (Quantity Level Limit)
  • Lidocaine-Prilocaine Cream 2.5-2.5% (Quantity Level Limit)
  • Liothyronine Tabs 5mcg, 50mcg (Quantity Level Limit)
  • Norethindrone Tab 5mg (Step Therapy Required)
  • Olanzapine ODT Tabs (Age Limit)
  • Olanzapine Tabs (Age Limit)
  • Quetiapine Tabs (Age Limit)
  • Risperidone ODT Tabs (Age Limit)
  • Risperidone Oral Solution 1mg/ml (Age Limit)
  • Risperidone Tabs (Age Limit)
  • Sertraline Concentrate Oral Solution 20mg/ml (Age Limit)
  • Thyroid Tabs 15mg, 30mg, 60mg, 90mg, 120mg (Quantity Level Limit)


July 2019


  • Cefixime Cap 400mg (Quantity Level Limit)
  • Erlotinib Tab 150mg (Prior Authorization Required)
  • Mesalamine DR Cap 400mg (Quantity Level Limit)


  • Suprax Cap 400mg (brand)
  • Tarceva Tab 150mg (brand)


June 2019


  • Docosanol Cream 10% (Quantity Level Limit)
  • Melatonin Tabs 1mg, 3mg, 5mg


  • Abreva Cream 10% (brand)


May 2019


  • Erythromycin Ethylsuccinate Suspension 400mg/5ml
  • Fulphila Injection 6mg/0.6ml (Prior Authorization Required)
  • Nivestym Injection 300mcg, 480mcg (Prior Authorization Required)
  • Sirolimus Solution 1mg/ml
  • Udenyca Injection 6mg/0.6ml (Prior Authorization Required)


  • Eryped Suspension (brand) 400mg/5ml
  • Rapamune Solution (brand) 1mg/ml



April 2019

Other Updates:

  • Antiretroviral Medications (Diagnosis Confirmation Required)


March 2019


  • Admelog Vial 300 units/3mL
  • Albuterol HFA Inhaler 90mcg – generic Ventolin HFA (Quantity Level Limit)
  • Arthritis Pain Relieving Cream 0.075%
  • Carafate Oral Suspension 1gm/10ml (Age Limit)
  • Mesalamine Suppository 1000mg
  • Toremifene Tab 60mg


  • Canasa Suppository 1000mg
  • Fareston Tab 60mg
  • Norethindrone Acetate & Estradiol-FE Tab 1mg-20mcg (24)

Other Updates:

  • Attention Deficit/Hyperactivity Disorder Stimulant Medications (Age Limit, Removed Prior Authorization)
  • Butalbital Containing Products (Quantity Level Limit)
  • Citalopram Oral Solution 10mg/5ml (Age Limit)
  • Dicyclomine Oral Solution 10mg/ml (Age Limit)
  • Escitalopram Oral Solution 5mg/5ml (Age Limit)
  • Famotidine Oral Suspension 40mg/5ml (Age Limit)
  • Lansoprazole Oral Suspension 3mg/ml (Age Limit)
  • Nitrofurantoin Oral Suspension 25mg/5ml (Age Limit)
  • Nortriptyline Oral Solution 10mg/5ml (Age Limit)
  • Omeprazole Oral Suspension 2mg/ml (Age Limit)
  • Oseltamivir Cap 30mg (Removed Age Limit)
  • Oseltamivir Oral Suspension 6mg/ml (Removed Age Limit)
  • Prednisone Oral Solution 5mg/5ml (Age Limit)


February 2019


  • Arnuity Ellipta Inhaler
  • Eligard Kit 7.5mg, 22.5mg, 30mg, 45mg (Prior Authorization Required)
  • Flebogamma IV Solution 5gm/50ml, 10gm/100ml, 20gm/200ml (Prior Authorization Required)
  • Immune Globulin IV Solution 1gm/10ml, 2.5gm/25ml, 5gm/50ml, 10gm/100ml, 20gm/200ml, 30gm/300ml, 40gm/400ml (Prior Authorization Required)
  • Leuprolide Acetate Kit 1mg/0.2ml (Prior Authorization Required)
  • Ozempic Injection (Quantity Level Limit, Step Therapy Required)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 27-0.8mg (Quantity Level Limit)
  • Prenatal Vitamin with Iron Carbonyl-Folic Acid Tab 29-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Minerals-Ferrous Fumarate-Folic Acid-DHA Pack 28-0.8-200mg (Quantity Level Limit)
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-Folic Acid Chewable Tab 29-1mg (Quantity Level Limit)
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid Cap 20-20-1.25mg (Quantity Level Limit)
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid Cap 130-92.4-1mg (Quantity Level Limit)
  • Segluromet Tabs (Quantity Level Limit, Step Therapy Required)
  • Steglatro Tabs (Quantity Level Limit, Step Therapy Required)
  • Victoza Injection (Quantity Level Limit, Step Therapy Required)



  • Alprazolam Orally Disintegrating Tabs
  • Cleocin Vaginal Ovule 100mg
  • Clorazepate Dipotassium Tabs
  • Condylox Gel 0.5%
  • Cortifoam Rectal Aerosol
  • Cuprimine Cap 250mg
  • Dihydroergotamine Mesylate Nasal Spray 4mg/ml
  • Dulera Inhaler
  • Elidel Cream 1%
  • Ergotamine SL Tab 2mg
  • Ergotamine-Caffeine Suppository 2-100mg
  • Ergotamine-Caffeine Tab 1-100mg
  • Flovent Diskus
  • Humalog Pens/Cartridges
  • Humalog Vials
  • Invokamet Tabs
  • Invokana Tabs
  • Levonorgestrel-Ethinyl Estradiol Tab 0.15-0.03mg (84) & Ethinyl Estradiol Tab 0.01mg (7)
  • Lidocaine-Hydrocortisone Rectal Kit 20x7gm
  • Lidocaine-Hydrocortisone Rectal Kit 3-1%
  • Meprobamate Tabs
  • Miconazole 3 Suppository 200mg
  • Nitro-Bid Cream Packets 2%
  • Novolog Pens/Cartridges
  • Novolog Vials
  • Plan B Tab (Brand Only)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 65-1mg
  • Prenatal Vitamin with Ferrous Fumarate-L Methylfolate-Folic Acid Tab 27-0.6-0.4mg
  • Prenatal Vitamin with Iron Polysaccharide Complex-Folic Acid Chew Tab 29-1mg
  • Prenatal Vitamin with Iron Polysaccharide Complex-L Methylfolate-Folic Acid Chew Tab 29-0.6-0.4mg
  • Prenatal Vitamin with Minerals with Iron Poly Saccharide Complex-Folic Acid-DHA Cap 29-1-200mg
  • Prenatal Vitamin with Minerals with Iron Poly Saccharide Complex-Folic Acid-DHA Pack 1mg & 250mg
  • Prenatal Vitamin without Vit A with Ferrous Asparto Glyc-L Methylfolate-Folic Acid- DHA Cap 10-0.6-0.4-200mg
  • Prenatal Vitamin without Vit A with Ferrous Asparto Glyc-L Methylfolate-Folic Acid- DHA Cap 18-0.6-0.4-300mg
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-DSS-Folic Acid-DHA Cap 27-1.25-300mg
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-L Methylfolate-Folic Acid-DHA Cap 27-0.6-0.4-300mg
  • Pulmicort Flexhaler
  • Qvar Inhaler
  • Relenza Diskhaler
  • Synjardy Tabs
  • Terconazole Vaginal Suppository 80mg
  • Thalomid Caps
  • Triazolam Caps
  • Trimethobenzamide Cap 300mg
  • Trulicity Injection

Other Updates:

  • Abilify Maintena Injection (Quantity Level Limit)
  • Acyclovir Suspension 200mg/5ml (Age Limit)
  • Alprazolam SR Tabs 0.5mg, 1mg, 2mg, 3mg (Age Limit)
  • Alprazolam Tabs 0.25mg, 0.5mg, 1mg, 2mg (Quantity Level Limit)
  • Aristada Injection (Quantity Level Limit)
  • Breo Ellipta Inhaler (Age Limit)
  • Calcipotriene Cream 0.005% (Quantity Level Limit)
  • Calcipotriene Ointment 0.005% (Quantity Level Limit)
  • Calcipotriene Solution 0.005% (Quantity Level Limit)
  • Chlordiazepoxide Caps 5mg, 10mg, 25mg (Quantity Level Limit)
  • Citalopram Solution 10mg/5ml (Age Limit)
  • Clozapine Tabs (Quantity Level Limit)
  • Dicyclomine Solution 10mg/ml (Age Limit)
  • Escitalopram Solution 5mg/5ml (Age Limit)
  • Famotidine Suspension 40mg/5ml (Age Limit)
  • Flovent HFA Inhaler (Age Limit)
  • Fluphenazine Concentrate 5mg/ml (Quantity Level Limit)
  • Fluphenazine Elixir 2.5mg/5ml (Quantity Level Limit)
  • Fluphenazine Injection 2.5mg/ml (Quantity Level Limit)
  • Fluphenazine Injection 25mg/ml (Quantity Level Limit)
  • Haloperidol Concentrate 2mg/ml (Quantity Level Limit)
  • Haloperidol Decanoate Injection 100mg/ml (Quantity Level Limit)
  • Haloperidol Decanoate Injection 50mg/ml (Quantity Level Limit)
  • Haloperidol Lactate Injection 5mg/ml (Quantity Level Limit)
  • Haloperidol Tabs (Quantity Level Limit)
  • Hydroxyzine Tabs 10mg, 25mg, 50mg (Quantity Level Limit)
  • Invega Sustena Injection (Quantity Level Limit)
  • Invega Trinza Injection (Quantity Level Limit)
  • Jardiance Tabs (Remove Step Therapy, Add Prior Authorization Required)
  • Lansoprazole Suspension 3mg/ml (Age Limit)
  • Lithium Carbonate Caps (Quantity Level Limit)
  • Lithium Carbonate ER Tab 300mg, 450mg (Quantity Level Limit)
  • Lithium Carbonate Tab 300mg (Quantity Level Limit)
  • Lithium Solution 8meq/5ml (Quantity Level Limit)
  • Lorazepam Tabs 0.5mg, 1mg, 2mg (Quantity Level Limit)
  • Loxapine Caps (Quantity Level Limit)
  • Nitrofurantoin Suspension 25mg/5ml (Age Limit)
  • Nortriptyline Solution 10mg/5ml (Age Limit)
  • Olanzapine Orally Disintegrating Tabs (Quantity Level Limit)
  • Olanzapine Tabs (Quantity Level Limit)
  • Omeprazole Suspension 2mg/ml (Age Limit)
  • Oseltamivir Cap 30mg (Quantity Level Limit, Age Limit)
  • Oseltamivir Caps 45mg, 75mg (Quantity Level Limit)
  • Oseltamivir Suspension 6mg/ml (Quantity Level Limit, Age Limit)
  • Oxazepam Caps 10mg, 15mg, 30mg (Quantity Level Limit)
  • Perphenazine Tabs (Quantity Level Limit)
  • Prednisone Solution 5mg/5ml (Age Limit)
  • Prenatal Vitamin with Docusate-Ferrous Fumarate-Folic Acid Tab 29-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Chewable Tab 29-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 27-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 28-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 29-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Folic Acid Tab 60-1mg (Quantity Level Limit)
  • Prenatal Vitamin with Ferrous Fumarate-Iron Polysaccharide Complex-Folic Acid-Omega 3 Cap 38-1mg (Quantity Level Limit)
  • Prenatal Vitamin without Vit A with Ferrous Fumarate-Folic Acid Cap 106.5-1mg (Quantity Level Limit)
  • Prochlorperazine Suppository 25mg (Quantity Level Limit)
  • Prochlorperazine Tabs (Quantity Level Limit)
  • Quetiapine Tabs (Quantity Level Limit)
  • Risperdal Consta Injection (Quantity Level Limit)
  • Risperidone Orally Disintegrating Tabs (Quantity Level Limit)
  • Risperidone Solution 1mg/ml (Quantity Level Limit)
  • Risperidone Tabs (Quantity Level Limit)
  • Thioridazine Tabs (Quantity Level Limit)
  • Thiothixene Caps (Quantity Level Limit)
  • Trifluoperazine Tabs (Quantity Level Limit)
  • Ziprasidone Caps (Quantity Level Limit)


January 2019

No Changes


Prior authorization for drugs

If the drug you are requesting is a statewide PDL drug, use the Universal Pharmacy Prior Authorization Fax Form, or appropriate drug specific form. 

If the drug you are requesting is an Aetna supplemental drug, use the Universal Pharmacy Prior Authorization Fax Form, or appropriate drug specific form.

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




Analgesics-Non-Opioid Barbiturate Combinations  Updated 01.01.2020

Analgesics-Opioids Long-Acting  Updated 01.01.2020

Analgesics-Opioids Short-Acting  Updated 01.01.2020

Antidepressants, Other  Updated 01.01.2020

Antihemophilia Agents  Updated 01.01.2020

Antipsychotics  Updated 01.01.2020

Blood Glucose Meters and Test Strips  Updated 01.01.2020

Botulinum Toxins  Updated 01.01.2020

Colony Stimulating Factors  Updated 01.01.2020

Cystic Fibrosis  

Cytokine and CAM Antagonists Updated 01.01.2020


Dupixent  Updated 01.01.2020

Erythropoiesis Stimulating Proteins  Updated 01.01.2020

Hepatitis C Agents Updated 01.01.2020

Intra-Articular Hyaluronates  Updated 01.01.2020

Intron A Alferon N 

Monoclonal Antibodies Anti-IL, Anti-IgE  Updated 01.01.2020

Multiple Sclerosis  Updated 01.01.2020

Non-Preferred Medication Updated 01.01.2020



Oncology Agents, Oral  Updated 01.01.2020

Opioid Dependence Treatments, Oral  Updated 01.01.2020

Opioid Dependence Treatments, Probuphine  Updated 01.01.2020

Opioid Dependence Treatments, Sublocade  Updated 01.01.2020

Pituitary Suppressive Agents, LHRH  Updated 01.01.2020

Sandostatin Analogs


Stimulants and Related Agents Updated 01.01.2020

Stimulants and Related Agents, Provigil, Nuvigil  Updated 01.01.2020


Synagis Updated 10.01.2019

Zoledronic Acid 


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

Universal Pharmacy Prior Authorization Fax Form CHIP






Anticoagulant Injectable Agents 


Atypical Antipsychotics Long-Acting Injectables

Atypical Antipsychotics Oral  UPDATED 08.23.2019

Botulinum Toxins


Celecoxib - Celebrex


CNS Stimulants (ADD/ADHD Medications) 

Colony Stimulating Factor 

Cystic Fibrosis  

Cytokine and CAM Antagonists  



DPP-4 Inhibitors



Estradiol Vaginal Cream

Factor IX Agents

Factor VIII Agents 




Growth Hormone 


Hepatitis C  

HIV Medications

Hyperlipidemia Medications (Epanova, Lovaza, Vascepa)

IL-5 Antagonists


Insulin Pens

Intron A Alferon N 


Juxtapid – Kynamro



Multiple Sclerosis Agents

Narcotic Analgesics - Long-Acting

Narcotic Analgesics - Short-Acting

Non-Formulary Medication

Novoseven RT




Omega 3 carboxylic acids (Epanova)

Oncology - Afinitor-Afinitor Disperz

Oncology - Capecitabine (Xeloda)

Oncology - Imatinib (Gleevec)

Oncology - Inlyta

Oncology - Nexavar

Oncology - Revlimid

Oncology - Sutent

Oncology -Tarceva

Oncology - Tykerb

Oncology - Votrient


Onychomycosis tinea 

PCSK9 Inhibitors 

Pegasys for hepatitis B

Platelet Inhibitors 



Pulmonary Arterial Hypertension




Sandostatin Analogs



SGLT2 Inhibitors

Somatostatin analogs


Synagis Updated 10.01.2019



Topical Hyaluronic Acid Derivatives





Zoledronic Acid 


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


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 06/2018)       

Anthelimintics (PARP approved 03/2019)                                                                                                                                                                                                              

Compound Guideline (PARP approved 12/2019)

Corlanor (PARP approved 02/2019)

Cystic Fibrosis (PARP approved 02/2019)

Daraprim (PARP approved 06/2018)    

Egrifta (PARP approved 03/2019)

Elmiron (PARP approved 06/2018)

Exondys (PARP approved 02/2019

Generic Substitution (PARP approved 12/2019)                                        

HP Acthar (PARP approved 12/2019)                                              

Interferons (non-Hepatitis C) (PARP approved 12/2019)  

IVIG Products  (PARP approved 12/2019) 

Korlym (PARP approved 02/2019)

L-Methylfolate Products (PARP approved 12/2019

Lucemyra (PARP approved 02/2019)                                                 

Multaq (PARP approved 02/2019)

Non-Formulary Medication (PARP approved 12/2019)

Nuedexta (PARP approved 12/2019)

Off Label Use (PARP approved 12/2019)

Quantity Limits (PARP approved 02/2019)

Sensipar (PARP approved 06/2018)

Somatostatin Analogs  (PARP approved 12/2019)

Spinraza (PARP approved 12/2019)

Synagis (PARP approved 12/2019)

Tranexamic Acid (PARP approved 02/2019)

Trial Dose Program (PARP approved 10/2014)

Zolgensma (PARP approved 12/2019)



To quickly find a prior authorization guideline, click "CTRL F" on your keyboard and type in the guideline name.


ADD/ADHD Non-Stimulants                 

ADD/ADHD Stimulants 


Anticoagulants - Oral 

Anticoagulants - Injectable 



Armodafinil and Modafinil             

Antipsychotics - Oral                                                                                         

Atypical Antipsychotics Long-Acting Injectables 

Bonjesta - Diclegis 

Botulinum Toxins                                         

Buprenorphine  Updated 01.01.2020

Calcitonin Gene-Related Peptide Receptor Antagonists 

Cialis for BPH                                 

Colony Stimulating Factors                         

Compound Guideline 


Cystic Fibrosis 

Cytokines and CAM Antagonists 



Diabetic Testing Supplies 

Direct Renin Inhibitors 







Erythropoiesis Stimulating Agents 

Estrace and Premarin Creams



Generic Substitution 

Gonadotropin Releasing Hormone Analogs 


Growth Hormone 


Hepatitis C 

Hereditary Angioedema Agents 


HP Acthar 

Human Immunodeficiency Virus                                           

Insulin Pens             

Interferons (non-Hepatitis C) 

Interleukin-5 Antagonist 

Intravaginal Progesterone 

IVIG Products  




Lidocaine Ointment 

Lidocaine Patches 




Monoamine Depletors                                                


Multiple Sclerosis including Ampyra 



Non-Formulary Medication 


Off Label Use 

Oncology - General 

Oncology - Inlyta 

Oncology - Revlimid 

Oncology - Second/Third Generation TKI (Iclusig, Sprycelm Tasigna, Bosulif) 

Oncology - Sutent 

Onychomycosis and Tinea 

Osteoporosis - Injectables 

Oral Liquids 


Pulmonary Arterial Hypertension 

Platelet Inhibitors 


Proton Pump Inhibitors 

Pulmonary Fibrosis Agents 

Quantity Limits 


Restasis and Xiidra 


Somatostatin Analogs  




Tranexamic Acid 

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

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:
  • 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
  • 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 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.