Pharmacy

Aetna Better Health’s formulary 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.

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.

You can view a list of recent formulary updates below.

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).

Visit Pharmacy Provider Search to view all the Aetna Better Health pharmacy providers.

December 2019

Removals:

  • PreNata Chewable Tab 29-1mg

 

November 2019

No Updates

 

October 2019

Other Updates:

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

 

September 2019

Additions:

  • 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)

Removals:

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

 

August 2019

Additions:

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

Removals:

  • 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

Additions:

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

Removals:

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

 

June 2019

Additions:

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

Removals:

  • Abreva Cream 10% (brand)

 

May 2019

Additions:

  • 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)

Removals:

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

 

 

April 2019

Other Updates:

  • Antiretroviral Medications (Diagnosis Confirmation Required)

 

March 2019

Additions:

  • 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

Removals:

  • 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

Additions:

  • 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)

 

Removals:

  • 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

 

December 2018

Additions:

  • Itraconazole Solution 10mg/ml
  • Nivestym Injection 300mcg, 480mcg (Prior Authorization Required)

Removals:

  • Gleostine Caps 10mg, 40mg, 100mg
  • Mometasone Nasal Spray
  • Nasonex Nasal Spray
  • Sporanox Solution 10mg/ml

 

November 2018

Additions:

  • Albendazole Tab 200mg (Step Therapy Required)

Removals:

  • Albenza Tab 200mg 

PA’s Prescription Drug Monitoring Program

Heroin and opioid overdose are now the leading cause of accidental death in Pennsylvania.

To help prevent prescription drug abuse and protect the health and safety of our community, Pennsylvania's Prescription Drug Monitoring Program (PA PDMP) collects information on all filled prescriptions for controlled substances. This information helps health care providers safely prescribe controlled substances and helps patients get the treatment they need.

As of January 1, 2017, all licensed prescribers who are lawfully authorized to distribute, dispense, or administer a controlled substance in the Commonwealth of Pennsylvania are required to register with the program.

Aetna Better Health encourages prescribers and dispensers to register with the PDMP today. Help patients get the treatment they need.

Prescriber Q&A

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

 

Acamprosate

Actimmune 

Alzheimers Agents

Analgesics Non Opioid Barbituate Combinations

Antianginal Agents - Ranexa

Antianginal Agents - Vasodilators Coranary

Antibiotics GI Related - Xifaxan

Antibiotics GI Related - Zinplava

Antipsychotics

Bile Salts

Bone Resorption Suppression Agents

Botulinum Toxins

Brand name drugs

Colony Stimulating Factors

COPD Agents

Cystic Fibrosis  

Cytokine and CAM Antagonists  

Dupixent

Daraprim 

Elmiron

Erythropoiesis Stimulating Proteins

Glucocorticoids

Hepatitis C Agents

Hereditary Angioedema Agents

HIV-AIDS Agents

Hypoglycemics - Incretin Enhancers (DPP-4 Inhibitors)

Hypoglycemics - Incretin Mimetics (GLP-1 Receptor Agonists)

Hypoglycemics - Insulin and Related Agents

Immunomodulators

Intra-articular Hyaluronates

Intron A Alferon N 

IVIG Products

Lipotropics, Other

Monoclonal Antibodies - Cinqair

Monoclonal Antibodies - Fasenra

Monoclonal Antibodies - Nucala

Monoclonal Antibodies - Xolair

Multiple Sclerosis Agents 

Multiple Sclerosis Agents - Ampyra

Multiple Sclerosis Agents - Aubagio

Multiple Sclerosis Agents - Gilenya

Multiple Sclerosis Agents - Lemtrada

Multiple Sclerosis Agents - Ocrevus

Multiple Sclerosis Agents - Tecfidera

Multiple Sclerosis Agents - Tysabri

Non-Formulary Medication

NSAIDs

Nuedexta

Octreotide

Opioid Analgesics - Long-acting

Opioid Analgesics - Short-acting

Opioid Dependence Treatments - Oral

Pegasys for hepatitis B

Pituitary Suppresive Agents

Platelet Aggregation Inhibitors

Progestational Agents

Proton Pump Inhibitors

Pulmonary Arterial Hypertension (PAH)

Sandostatin Analogs

Sedative Hypnotics

Sensipar

Skeletal Muscle Relaxants

Somatostatin analogs

Stimulants and Related Agents

Sylatron

Synagis Updated 10.01.2019

Thrombopoietics - Nplate

Thrombopoietics - Promacta

VMAT2 Inhibitors - Austedo

VMAT2 Inhibitors - Ingrezza

VMAT2 Inhibitors - Tetrabenazine and Xenazine

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

 

Acamprosate

Actimmune 

Alphanate-Humate 

Ampyra

Anticoagulant Injectable Agents 

Aranesp

Atypical Antipsychotics Long-Acting Injectables

Atypical Antipsychotics Oral  UPDATED 08.23.2019

Botulinum Toxins

Brand name drugs

Buprenorphine-Naloxone  

Celecoxib - Celebrex

Cialis 

CNS Stimulants (ADD/ADHD Medications) 

Colony Stimulating Factor 

Cystic Fibrosis  

Cytokine and CAM Antagonists  

Daliresp 

Daraprim 

DPP-4 Inhibitors

Elmiron

Epogen-Procrit 

Erivedge

Estradiol Vaginal Cream

Factor IX Agents

Factor VIII Agents 

Feiba

Forteo

GLP-1

Growth Hormone 

Hemlibra

Hepatitis C  

HIV Medications

Hyperlipidemia Medications (Epanova, Lovaza, Vascepa)

IL-5 Antagonists

Increlex

Insulin Pens

Intron A Alferon N 

IVIG Products

Jardiance

Juxtapid – Kynamro

Lyrica 

Movantik 

Multiple Sclerosis Agents

Narcotic Analgesics - Long-Acting

Narcotic Analgesics - Short-Acting

Non-Formulary Medication

Novoseven RT

Nuedexta

Obizur

Octreotide

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

Ondansetron

Onychomycosis tinea 

PCSK9 Inhibitors 

Pegasys for hepatitis B

Platelet Inhibitors 

Prolia 

Promacta 

Pulmonary Arterial Hypertension

Ranexa

Restasis-Xiidra

Rosuvastatin

Sandostatin Analogs

Savella

Sensipar

SGLT2 Inhibitors

Somatostatin analogs

Sylatron

Synagis Updated 10.01.2019

Tavalisse

Testosterone

Topical Hyaluronic Acid Derivatives

Toujeo

Tymlos

Wilate-Vonvendi

Xolair 

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

PCN: ADV

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 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 12/2018)

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 4/2019)                                        

HP Acthar (PARP approved 02/2019)                                              

Interferons (non-Hepatitis C) (PARP approved 06/2018)  

IVIG Products  (PARP approved 02/2018) 

Korlym (PARP approved 02/2019)

Lucemyra (PARP approved 02/2019)                                                 

Multaq (PARP approved 02/2019)

Non-Formulary Medication (PARP approved 03/2019)

Nuedexta (PARP approved 09/2018)

Off Label Use (PARP approved 02/2017)

Quantity Limits (PARP approved 02/2019)

Sensipar (PARP approved 06/2018)

Somatostatin Analogs  (PARP approved 06/2018)

Synagis (PARP approved 09/2018)

Tranexamic Acid (PARP approved 02/2019)

Trial Dose Program (PARP approved 10/2014)

 

 

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

Acamprosate (PARP approved 06/2018)

ADD/ADHD Non-Stimulants (PARP approved 02/2019)                  

ADD/ADHD Stimulants (PARP approved 02/2019)

Anthelimintics (PARP approved 03/2019)                       

Anticoagulants - Oral (PARP approved 02/2019)

Anticoagulants - Injectable (PARP approved 09/2018)

Antidepressants (PARP approved 03/2019)                               

Antihyperlipidemics (PARP approved 07/2018)

Armodafinil and Modafinil (PARP approved 02/2019)               

Antipsychotics - Oral (PARP approved 03/2019)                                                                                            

Atypical Antipsychotics Long-Acting Injectables (PARP approved 02/2019) 

Bonjesta - Diclegis (PARP approved 02/2019)   

Botulinum Toxins    (PARP approved 11/2017)                                        

Buprenorphine (PARP approved 02/2019)

Calcitonin Gene-Related Peptide Receptor Antagonists (PARP approved 02/2019)

Cialis for BPH (PARP approved 06/2018)                                   

Colony Stimulating Factors (PARP approved 02/2019)                          

Compound Guideline (PARP approved 12/2018)

Corlanor (PARP approved 02/2019)

Cystic Fibrosis (PARP approved 02/2019) 

Cytokines and CAM Antagonists (PARP approved 03/2019)

Daliresp (PARP approved 09/2018)

Daraprim (PARP approved 06/2018)    

Diabetic Testing Supplies (PARP approved 06/2018)

Direct Renin Inhibitors (PARP approved 02/2019)

Dupixent (PARP appoved 03/2019)

Egrifta (PARP approved 03/2019)

Elmiron (PARP approved 06/2018)

Emflaza (PARP approved 03/2019)

Entresto (PARP approved 03/2019)    

Epidiolex (PARP approved 03/2019)                         

Erythropoiesis Stimulating Agents (PARP approved 06/2018)

Estrace and Premarin Creams (PARP 09/2018)

Eucrisa (PARP approved 02/2019)

Exondys (PARP approved 02/2019

Generic Substitution (PARP approved 4/2019)

Gonadotropin Releasing Hormone Analogs (PARP approved 02/2019)

Griseofulvin (PARP approved 02/2019)      

Growth Hormone (PARP approved 06/2018)

Hemophilia (PARP approved 06/2018)                                                  

Hepatitis C (PARP approved 02/2019)

Hereditary Angioedema Agents (PARP approved 02/2019)

Hetlioz (PARP approved 03/2019

HP Acthar (PARP approved 02/2019)

Human Immunodeficiency Virus (PARP approved 12/2018)                                             

Insulin Pens (PARP approved 06/2018)                

Interferons (non-Hepatitis C) (PARP approved 06/2018)  

Interleukin-5 Antagonist (PARP approved 03/2018)

Intravaginal Progesterone (PARP approved 02/2019)

IVIG Products  (PARP approved 02/2018) 

Jakafi (PARP approved 02/2019)

Jardiance (PARP approved 02/2019)

Korlym (PARP approved 02/2019)

Lidocaine Ointment (PARP approved 02/2019)

Lidocaine Patches (PARP approved 05/2019)

Lucemyra (PARP approved 02/2019)

Lyrica (PARP approved 06/2018)   

Makena (PARP approved 11/2018)  

Monoamine Depletors (PARP approved 02/2019)                                                  

Movantik (PARP approved 06/2018)

Multiple Sclerosis including Ampyra (PARP approved 01/2018)

Multaq (PARP approved 02/2019)

Narcotic  (PARP approved 08/2018)

Non-Formulary Medication (PARP approved 03/2019)

Nuedexta (PARP approved 09/2018)

Off Label Use (PARP approved 02/2017)

Oncology - General (PARP approved 01/2019)

Oncology - Inlyta (PARP approved 10/2014)

Oncology - Revlimid (PARP approved 01/2016)

Oncology - Second/Third Generation TKI (Iclusig, Sprycelm Tasigna, Bosulif) (PARP approved 02/2019)

Oncology - Sutent (PARP approved 01/2016)

Onychomycosis and Tinea (PARP approved 06/2018)

Osteoporosis - Injectables (PARP approved 09/2018)

Oral Liquids (PARP approved 02/2019)

Otezla (PARP approved 02/2019)

Pulmonary Arterial Hypertension (PARP approved 01/2019)

Platelet Inhibitors (PARP approved 09/2018)

Promacta (PARP approved 06/2018)

Proton Pump Inhibitors (PARP approved 09/2018)

Pulmonary Fibrosis Agents (PARP approved 12/2018)

Quantity Limits (PARP approved 02/2019)

Ranexa (PARP approved 09/2018)

Restasis and Xiidra (PARP approved 09/2018)

Sensipar (PARP approved 06/2018)

Somatostatin Analogs  (PARP approved 06/2018)

Synagis (PARP approved 09/2018)

Testosterone (PARP approved 06/2018)

Tavalisse (PARP approved 09/2018)

Tranexamic Acid (PARP approved 02/2019)

Trial Dose Program (PARP approved 10/2014)

Viscosupplements (PARP approved 02/2019)

Xifaxan (PARP approved 01/2019)

Xolair (PARP approved 09/2018)

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: https://www.pharmblue.com
  • 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
  • HIV/AIDS
  • 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 Specialtypharmacyapplications@cvscaremark.com. 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 formulary (preferred drug list) as well as all clinical criteria for utilization management.  All P&T changes 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.