Member Pharmacy Benefits

Prescription Drugs

Prescription drugs are often an important part of your health care. As an Aetna Better Health of Michigan member, you have the right to certain prescription drug benefits.

Aetna Better Health of Michigan covers prescription drugs and certain over – the – counter drugs when presented with a prescription at a pharmacy.

A formulary is a list of drugs that Aetna Better Health covers and the formulary consists of the MDHSS PDL and Common Formulary. To find out it if a drug that you take is covered, you can check the MDHSS PDL and Common Formulary for the most current coverage status.  Aetna Better Health also covers diabetic supplies. The preferred Glucose meters and Test Strips are J&J One Touch products. The preferred pen needles are BD. As of 9/1/2022, The preferred continuous glucose monitors (CGMs) are Dexcom G6 and Freestyle Libre (both require prior authorization).

You may also request a printed copy of this formulary by calling Member Services. If you have any questions about a drug that is not listed, please call Member Services toll-free at 1-866-316-3784 (TTY 711), 24 hours a day, 7 days a week.

If a drug is not listed on the formulary, a Pharmacy Prior Authorization Request form must be completed. Your doctor will complete this form. They must show why a formulary drug will not work for you. They must include any medical records needed for the request.

The Pharmacy Prior Authorization form is available on our website. Your doctor may make a request by telephone at 1-866-316-3784, via fax 1-855-799-2551, or through CoverMyMeds.com

Aetna Better Health of Michigan Members must have their prescriptions filled at a in network pharmacy to have their prescriptions covered at no cost to them. You may go to our website to search for an in-network pharmacy near your zip code.

Formulary Updates

Updates to the PDL/Common Formulary can be found online using the formulary documents linked below:

• PDL
• Common Formulary

Carve-Out Drugs

MDHSS carves out specific classes of drugs. These drugs are covered by MDHSS Fee-or-service (FFS) using the Magellan Pharmacy Benefit Manager

For more information about MDHSS Fee-for-service carve outs please click here.

For confirmation of carved out agents use the FFS drug search tool

Prior Authorization Process

Aetna Better Health of Michigan’s pharmacy prior authorization (PA) process is designed to approve drugs that are medically needed. We require doctors to obtain a PA before prescribing or giving out the following:

• Injectable drugs provided by a pharmacy
• Non-formulary drugs that are not excluded under a State’s Medicaid program
• Prescriptions that do not follow our guidelines (like quantity limits, age limits or step therapy)
• Brand name drugs, when a generic is available

Aetna Better Health of Michigan’s Medical Director decides if a drug is denied or approved using MDHSS guidelines. The Medical Director may need additional information before making a decision. This information may include the following:

• Drugs on the formulary have been tried and does not work (i.e., step therapy)
• No other drugs on the formulary would work as well as the drug requested
• The request is acceptable by the Federal Drug Administration (FDA) or is accepted by nationally noted experts
• For brand name drug requests, a completed FDA MedWatch form documenting failure or issues with the generic equal is required.

Both parties will be told of the decision through the telephone or mail.

Aetna Better Health of Michigan will fill prescriptions for a seventy-two (72) hour supply if the member is waiting for a decision by the Plan.

If a drug is not listed on the formulary, a Pharmacy Prior Authorization Request form must be completed. Your doctor will have to complete this form. They must show why a formulary drug will not work for you. They must include any medical records needed for the request.

The Pharmacy Prior Authorization form is available on our website. Your doctor may make a request by telephone at 1-866-316-3784, via fax 1-855-799-2551, or through CoverMyMeds.com.

Step Therapy and Quantity Limits

The step therapy program requires certain drugs, such as generic drugs or formulary brand drugs to be prescribed before a specific second-line drugs is approved. Drugs having step therapy are listed on the formulary with “STEP”. Certain drugs on the Aetna Better Health of Michigan formulary have quantity limits and are listed on the formulary with “QLL”

The QLLs are based on the MDHSS PDL and Common Formulary.

Your doctor can request an override step therapy and/or a quantity limit by telephone at 1-866-316-3784, via fax 1-855-799-2551, or through CoverMyMeds.com

CVS Caremark Specialty Pharmacy

Aetna Better Health Specialty Drugs may be filled by CVS Health Specialty Pharmacy. A Specialty pharmacy fills drugs but has other services to help you. The Specialty Drug Program has special services for you:

• You can talk to a Pharmacist 24 hours a day, seven days a week
• Disease-specific education and counseling are available by CVS
• Care Coordination for you and your doctor
• Delivery of Specialty drugs to your home and/or your doctor’s office is available for drop off and pick up at any CVS Pharmacy location (including those inside Target stores*)

You can contact CVS Specialty Pharmacy at 1-800-237-2767; TTY/TDD: 1-800-863-5488 from 7:30 a.m. (EST) to 9:00 p.m. (EST) time, Monday – Friday. CVS Specialty Pharmacy will assist you in filling your specialty drug.

Mail Order Prescriptions

Aetna Better Health of Michigan offers mail order prescription services through CVS Caremark. Use one of the following to request this service:

• Call CVS Caremark, toll free at 1-800-552-8159/TTY 711, Monday to Friday between 8 a.m. and 8 p.m., for help to sign up for mail order service. CVS Caremark will call the prescribing provider to get the prescription with the member’s ok.

• Go online
• Log in and sign up for mail service online. If the member gives an ok, CVS Caremark will call the prescribing provider to get the prescription.
• By requesting your doctor to write a prescription for a 90-day supply with up to one year of refills. CVS Caremark will mail a mail service order form. When the member receives the form, the member fills it out and mails CVS Caremark the prescription and the order form. Forms should be mailed to:

CVS CAREMARK

PO BOX 94467PALATINE

IL 60094-4467

We Treat Hep C

MDHHS is partnering Aetna Better Health® in the We Treat HEP C Initiative

Hep C treatment no longer requires a prior authorization if using the State Preferred PDL agent Mavyret®. Hep C treatment is carved out to MDHHS fee for service (MagellanRx) and as 4/1/2021 the system is set up to approve Mavyret® for up to a 12 week supply. Network pharmacies have also been made aware of the changes to the PA status of Mavyret® and should be prepared to dispense accordingly.

Please see the below FAQ for further information for prescribers of Mavyret ® as part of the We Treat HEP C Initiative:

1. Which type of provider may prescribe Mavyret®?
• All MDHHS registered prescribers, including non-specialists, will be able to prescribe Mavyret® as of 4/1/2021
2. What has to be submitted with a MAVYRET® claim now that no PA is required?
   • The claim will be paid if submitted in accordance with our Pharmacy Claims Processing Manual: https://michigan.magellanrx.com/provider/external/medicaid/mi/doc/en- us/MIRx_D0_claims_processing_manual.pdf. Diagnosis codes are not required on these claims.
3. Will MAVYRET® be covered without a PA in the rare case a patient requires 12 weeks of therapy?
   • Yes
4. For patients currently taking another Direct-Acting Antiviral (DAA) therapy (Zepatier, Epclusa, etc.), will they be able to complete their course of therapy (i.e., refills)?
   • Yes
5. Will there be specific PA criteria listed in the PDL for the non-preferred DAAs?
• Non-preferred DAAs will require a PA explaining why MAVYRET® is not clinically appropriate: MIRx_PAfaxform_General.pdf (magellanrx.com)
6. Are prisoners covered by Medicaid upon release and therefore able to get MAVYRET® without a PA?
• We are working on a Targeted Case Management benefit that provides support and resources for individuals recently released from a correctional facility, including some degree of in-reach, but this has not yet been implemented.
7. Can patients fill their MAVYRET® prescription at any Specialty or Retail Pharmacy?
• Yes
8. What is the co-pay for MAVYRET® under this agreement? What is the co-pay for a non-preferred DAA?
• For Medicaid, co-pay for MAVYRET® is $1, and co-pay for non-preferred DAAs are $3. There are no co-pays for viral hepatitis treatments for Healthy Michigan Plan.
9. Can more than 4 weeks of therapy be prescribed at a single time (e.g., 8 weeks of therapy, or less frequently 12 weeks of therapy, as opposed to 4 weeks with refill(s))?
• Pharmacies are authorized to dispense up to 102 days of therapy at a single time. However, many pharmacies may default to dispensing in 4-week increments, unless the script specifies an 8- or 12-week supply.   
10. Is MAVYRET® covered for patients on Emergency Services Only (ESO) Medicaid?
• Yes. MAVYRET® is covered for beneficiaries on Emergency Service (ESO) Medicaid. The Pharmacy should indicate level of service 3 (emergency) on the claim.

COVID-19 Testing- Members

ABH of MI covers COVID-19 self-test kits through the pharmacy benefit without a prescription. Members may go to an in-network pharmacy and receive up to 8 self-test kits per month.

For more information on which test kits are covered, please click here.

Medication recalls

Need information about medication recalls?  Just call the U.S. Food and Drug Administration (FDA) at 1-888-463-6332. Or visit the drug recalls page on the FDA website.