Member Pharmacy Benefits

Formulary search tool

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), 

Note:  Effective 6/1/2016, Aetna Better Health of MI will be transitioning to Michigan's Commn Drug Formulary.  For further information, click here.  

You can download the formulary (Michigan Medicaid Formulary). You can also view a list of this month's formulary updates below.

Pharmacy Billing Information

Aetna Better Health of MI members may use the following information along with the ID number to process prescriptions at network pharmacies:

  • BIN: 610591
  • PCN: ADV
  • GROUP: RX8826

Pharmacy providers may go to CVS/Caremark for payer sheets and additional network or processing information.

October 2019

Additions:

  • Krintafel 150mg Tablet (Prior Authorization Required, Quantity Level Limit)
  • Spiriva Respimat 1.25mcg Inh (Prior Authorization Required, Quantity Level Limit)
  • Symjepi 0.3mg/0.3ml Syringe (Quantity Level Limit)
  • Tretinoin 0.025% Cream (Quantity Level Limit, Step Therapy)

Removals:

  • Ciprofloxacin HCl 100 Mg Tab
  • Econazole Nitrate 1% Cream
  • Norethindrone & Mestranol Tab 1mg-50mcg
  • Tetracycline 250mg Capsule
  • Tetracycline 500mg Capsule

Other Updates:

  • Adefovir Dipivoxil 10mg Tab (Added Quantity Level Limit)
  • Entecavir 0.5mg Tablet (Added Quantity Level Limit)
  • Entecavir 1mg Tablet (Added Quantity Level Limit)
  • Lamivudine 100mg Tablet (Added Quantity Level Limit)

 

September 2019

Additions:

  • Febuxostat Tab (Quantity Level Limit, Prior Authorization)

Removals:

  • Uloric Tab

Other Updates:

  • Ninguna

 

Agosto 2019

Additions:

  • Butenafine HCl Cream 1%

Removals:

  • Ninguna

Other Updates:

  • Ciclopirox Olamine Cream 0.77% (Added Step Therapy)

 

July 2019

Additions:

  • Actemra 162 Mg/0.9 Ml Syringe (Quantity Level Limit, Prior Authorization Required)
  • Actemra Actpen 162 Mg/0.9 Ml (Quantity Level Limit, Prior Authorization Required)
  • Aimovig 140 Mg/Ml Autoinjector (Quantity Level Limit, Prior Authorization Required)
  • Cimzia 200 Mg Vial Kit (Quantity Level Limit, Prior Authorization Required)
  • Cimzia 200 Mg/Ml Starter Kit (Quantity Level Limit, Prior Authorization Required)
  • Cimzia 200 Mg/Ml Syringe Kit (Quantity Level Limit, Prior Authorization Required)
  • Orencia 50 Mg/0.4 Ml Syringe (Quantity Level Limit, Prior Authorization Required)
  • Orencia 87.5 Mg/0.7 Ml Syringe (Quantity Level Limit, Prior Authorization Required)
  • Orencia 125 Mg/Ml Syringe (Quantity Level Limit, Prior Authorization Required)
  • Orencia Clickject 125 Mg/Ml (Quantity Level Limit, Prior Authorization Required)
  • Siliq 210 Mg/1.5 Ml Syringe (Quantity Level Limit, Prior Authorization Required)
  • Xeljanz 10 Mg Tablet (Quantity Level Limit, Prior Authorization Required)
  • Xeljanz 5 Mg Tablet (Quantity Level Limit, Prior Authorization Required)
  • Xeljanz Xr 11 Mg Tablet (Quantity Level Limit, Prior Authorization Required)

Removals:

  • Captopril 100 Mg Tablet
  • Captopril 12.5 Mg Tablet
  • Captopril 25 Mg Tablet
  • Captopril 50 Mg Tablet
  • Dextromethorphan-Guaifenesin 10-100/5ml
  • Guaifenesin Syrup 100 Mg/5ml
  • Hydrocortisone Val 0.2% Cream
  • Pediatric Multiple Vitamin W/ Minerals & C
  • Polyethylene Glycol 3350 Oral Packet
  • Tekturna Hct 150-12.5 Mg Tablet
  • Tekturna Hct 150-25 Mg Tablet
  • Tekturna Hct 300-12.5 Mg Tablet
  • Tekturna Hct 300-25 Mg Tablet

Other Updates:

  • Azelastine Hcl 0.05% Drops (Added Step Therapy)
  • Entresto 24 Mg-26 Mg Tablet (Removed Prior Authorization, Added Age Minimum, Added Step Therapy, Added Quantity Level Limit)
  • Entresto 49 Mg-51 Mg Tablet (Removed Prior Authorization, Added Age Minimum, Added Step Therapy, Added Quantity Level Limit)
  • Entresto 97 Mg-103 Mg Tablet (Removed Prior Authorization, Added Age Minimum, Added Step Therapy, Added Quantity Level Limit)
  • Lidocaine 4% Cream (Added Quantity Level Limit)

 

June 2019

Additions:

  • Docosanol Cream 10%

Removals:

  • Abreva Cream 10%
  • Dextromethorphan-Guaifenesin 10-100/5ml
  • Guaifenesin Syrup 100 Mg/5ml
  • Pediatric Multiple Vitamin W/ Minerals & C

Other Updates:

  • Ninguna

 

Mayo 2019

Additions:

  • Nivestym Inj (Prior Authorization Required)
  • Ranolazine Tab 1000mg ER (Prior Authorization Required)
  • Aliskiren Tab (Quantity Level Limit, Prior Authorization Required)

Removals:

  • Ranexa Tab 1000mg ER
  • Tekturna Tab

Other Updates:

  • Ninguna

 

April 2019

Additions:

  • Aimovig Sol 70mg (Prior Authorization, Quantity Level Limit)
  • Bevespi Aero 9-4.8mcg (Step Therapy)
  • Daurismo Tab 25mg, 100mg (Prior Authorization)
  • Fluticasone-Salmeterol Aero 100-50mcg, 250/50mcg, 500/50mcg (Prior Authorization)
  • Fulphila Syr 6mg (Prior Authorization)
  • Granix Vial 300mcg, 480mcg (Prior Authorization)
  • Humalog Vial 100 Unit (Prior Authorization, Quantity Level Limit)
  • Olumiant Tab 2mg (Prior Authorization, Quantity Level Limit)
  • Ranolazine Tab ER 500mg
  • Sevelamer Tab 400mg, 800mg (Prior Authorization)
  • Symbicort Inh 160-4.5mcg (Age Limit, Quantity Level Limit)
  • Venclexta Tab 10mg, 50mg, 100mg/ Venclexta Starter Pack (Prior Authorization)
  • Xyrem Sol 500mg/mL (Prior Authorization, Quantity Level Limit)

Removals:

  • Advair Diskus 100/50mcg, 250/50mcg, 500/50mcg
  • Amantadine Tab 100mg
  • Fenoprofen Tab 600mg
  • Hydroxyzine Cap 100mg
  • Ranexa ER Tab 500mg
  • Ranitidine Cap 150mg, 300mg
  • Renagel Tab 400mg, 800mg
  • Xarelto Tab 2.5mg

Other Updates:

  • Bromocriptine Cap 5mg (Quantity Level Limit added)
  • Carbidopa-Levodopa Tab 25-100mg ODT (Quantity Level Limit removed)
  • Dalfampridine ER Tab 10mg (Quantity Level Limit added)
  • Imiquimod Crm 5% (Prior Authorization removed)
  • Rivastigmine Cap 1.5mg, 3mg, 4.5mg, 6mg (Quantity Level Limit added)

 

Marzo 2019

Additions:

  • Cinacalcet HCL 30mg, 60mg, 90mg Tab (Prior Authorization, Quantity Level Limit)
  • Pimecrolimus 1% Crm (Prior Authorization, Quantity Level Limit)
  • Toremifene Citrate 60mg Tab (Prior Authorization)

Removals:

  • Elidel 1% Crm
  • Fareston 60mg Tab
  • Sensipar 30mg, 60mg, 90mg Tab

 

Febrero 2019

Removals:

  • Fluticasone Prop Aer Pow 100mcg, 250mcg, 50mcg
  • Trulicity Inj 0.75mg/0.5mL, 1.5mg/0.5mL

Other Updates:

  • Flovent HFA 44mcg, 110mcg, 220mcg (Age Limit added)
  • Lansoprazole Susp 3mg/mL (Age Limit added)

 

Enero 2019

Additions:

  • Erleada 60mg Tab (Prior Authorization, Quantity Level Limit)
  • Ozempic Dose Pen (Quantity Level Limit, Step Therapy)
  • Pertzye DR 8,000U, 16,000U, 24,000U Caps (Quantity Level Limit)
  • Tibsovo 250mg Tab (Prior Authorization, Quantity Level Limit)
  • Viokace Tabs (Quantity Level Limit)
  • Xarelto Starter Pack (Prior Authorization, Quantity Level Limit)
  • Zytiga 500mg Tab (Prior Authorization, Quantity Level Limit)

Removals:

  • Diphenoxylat-Atropine 2.5-0.025/5mg/5mL Liquid
  • Humulin R 500u Kwikpen
  • Tanzeum Pen Injector

Other Updates:

  • Afinitor 7.5mg, 10mg Tab (Quantity Level Limit)
  • Alogliptin Tabs (Prior Authorization removed, Quantity Level Limit, Step Therapy added)
  • Alogliptin-Metformin Tabs (Prior Authorization removed, Quantity Level Limit, Step Therapy added)
  • Alogliptin-Pioglitazone Tabs (Prior Authorization removed, Step Therapy added)
  • Chlorzoxazone 500mg Tab (Age Limit)
  • Cyclobenazprine 5mg, 10mg Tabs (Age Limit)
  • Eliquis Starter Pack (Quantity Level Limit, Age Limit)
  • Eliquis Tabs (Quantity Level Limit, Age Limit)
  • Estradiol Patches (Age Limit)
  • Estradiol-Noreth 0.5-0.1mg, 1-0.5mg Tabs (Age Limit)
  • Menest Tabs (Age Limit)
  • Methocarbamol 500mg, 750mg Tabs (Age Limit)
  • Norethind-Eth Estradiol 0.5-2.5mcg (Quantity Level Limit, Age Limit)
  • Norethind-Eth Estradiol 1mg-5mcg (Age Limit)
  • Orphenadrine ER 100mg Tab (Age Limit)
  • Premphase 0.625-5mg Tab (Age Limit)
  • Prempro Tabs (Age Limit)
  • Tizanidine HCL Tabs (Age Limit)
  • Xarelto 10mg, 15mg, 20mg Tabs (Quantity Level Limit, Age Limit)

 

Diciembre 2018

Additions:

  • Nivestym solution 300mcg/0.5mL syr (Prior Authorization)
  • Nivestym solution 480mcg/0.8mL syr (Prior Authorization)
  • Xarelto 2.5mg tab (Prior Authorization, Quantity Level Limit)

Removals:

  • Taliva 1mg cap

Other Updates:

  • Xarelto 10mg, 15mg, 20mg tabs (Quantity Level Limit)

 

November 2018

No changes

 

October 2018

Additions:

  • Braftovi 50mg, 75mg Cap (Prior Authorization)
  • Isotretinoin 10mg, 20mg, 30mg, 40mg Cap (Prior Authorization, Quantity Level Limit)
  • Levalbuterol HFA 45mcg Inhaler (Step Therapy, Quantity Level Limit)
  • Loratadine 5mg Chew (Quantity Level Limit)
  • Nephrovite Tab
  • Prasugrel 5mg, 10mg Tab (Quantity Level Limit)
  • Retacrit Inj 2000unit, 3000unit, 4000unit, 10000unit, 40000unit (Prior Authorization)
  • Segluromet 2.5-1000mg Tab (Step Therapy)
  • Segluromet 2.5-500mg Tab (Step Therapy)
  • Segluromet 7.5-1000mg Tab (Step Therapy)
  • Segluromet 7.5-500mg Tab (Step Therapy)
  • Steglatro 5mg, 15mg Tab (Step Therapy)
  • Tadalafil (PAH) 20mg Tab (PA, Quantity Level Limit)
  • Yonsa 125mg Tab (Prior Authorization)

Removals:

  • Adcirca 20mg Tab
  • Aerospan 80mcg Inhaler
  • Apidra 100 unit/mL Solostar
  • Apidra 100 unit/mL Vial
  • Dulera 100-5mcg Inhaler
  • Dulera 200-5mcg Inhaler
  • Humalog 100 unit/mL Cartridge
  • Humalog 100 unit/mL Kwikpen
  • Humalog 100 unit/mL Vial
  • Novolog 100 unit/mL Cartridge
  • Novolog 100 unit/mL Flex pen
  • Novolog 100 unit/mL Vial
  • Qvar 40 mcg Inhaler
  • Qvar 80 mcg Inhaler
  • Symbicort 160-4.5mcg Inhaler

Other Updates:

  • Admelog 100 unit/mL Solostar (Quantity Level Limit)
  • Admelog100 unit/mL Vial (Quantity Level Limit)
  • Epinephrine 0.15mg Auto-inject (Quantity Level Limit)
  • Epinephrine 0.3mg Auto-inject (Quantity Level Limit)
  • Montelukast 10mg Tab (Age Limit removed)
  • Montelukast 4mg Chew (Age Limit removed)
  • Montelukast 5mg Chew (Age Limit removed)
  • Norethin-Eth Estradiol-Fe 0.4-35mg-mcg Chew (Prior Authorization removed)
  • Symbicort 80-4.5mcg Inhaler (Age Limit)
  • Zenpep DR 25,000 unit Cap (Quantity Level Limit)

Medicamentos con receta 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.

To find out it if a drug that you take is covered, you can check our formulary. A formulary is a list of drugs that Aetna Better Health covers. You can use the prescription drug search tool to find out if a drug is covered. 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 or via fax 1-855-799-2551.

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.

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 our 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.

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 FDA-approved doses and on nationally noted guidelines.

Your doctor can request an override step therapy and/or a quantity limit. They can fax a Pharmacy Prior Authorization Request form with medical records to 1-855-799-2551.

CVS Caremark Specialty Pharmacy:

Los medicamentos especiales de Aetna Better Health son suministrados por CVS Health Specialty Pharmacy. Una farmacia especializada suministra medicamentos pero también tiene otros servicios para ofrecerle. El programa de medicamentos especiales tiene servicios especiales para usted:

  • Puede hablar con un farmacéutico las 24 horas del día, los siete días de la semana
  • También a través de CVS hay información específica de la enfermedad y orientación
  • Coordinación de la atención médica para usted y su médico
  • En cualquier ubicación de CVS Pharmacy hay entrega y retiro de medicamentos especializados para usted, su hogar o el consultorio de su médico (incluidas las que están en las tiendas Target*)

Puede comunicarse con CVS Specialty Pharmacy al 1-800-237-2767; TTY/TDD: 1-800-863-5488 de 7:30 a.m. (EST) hasta 9:00 p.m. (EST), de lunes a viernes. CVS Specialty Pharmacy le ayudará a obtener su medicamento especializado. La lista de medicamentos especializados está aquí.

Preguntas frecuentes

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 94467

               PALATINE, IL 60094-4467