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Pharmacy benefits

The pharmacy benefit for outpatient prescription medication is carved out to the Bureau for Medical Services (BMS). Gainwell Technologies is the pharmacy benefits manager (PBM) handling these prescriptions for Medicaid. CVS Caremark® is the PBM for the Childrens Health Insurance Program (CHIP). Medications administered in provider offices and inpatient facilities are still covered by Aetna Better Health® of West Virginia.

Outpatient medications


Questions about a member’s pharmacy benefits or a specific medication?  


For Medicaid:

Contact Gainwell Technologies’ pharmacy help desk at 1-800-847-3859. Or visit the BMS website to see the state’s Preferred Drug List (PDL) and coverage details.



Contact CVS Caremark at 1-800-241-3260, or view a copy of the current CHIP PDL (PDF).

Inpatient medications


Questions about medications a member receives in a provider’s office, hospital or infusion center setting?


Just call us at 1-888-348-2922 (TTY: 711). We’re here for you 24 hours a day, 7 days a week.

Medical pharmaceutical management

Medical pharmaceutical management

Pharmacy coverage updates


We inform our members and prescribing providers of updates once a year, as well as any time we make a change. This information includes: 


  • A list of code changes determined by BMS and the Aetna® Utilization Management Steering Committee (UMSC)
    • This list includes (but is not limited to) changes to prior authorization (PA) requirements.
  • A reminder that Aetna Better Health does not manage:
    • Prescriptions
    • Generic substitution
    • Step therapy
    • Therapeutic interchange
  • Nor do we:
    • Administer a closed formulary for medical pharmaceuticals
    • Use a formulary for management of medical pharmaceuticals
  • Details on a provider’s or member’s right to appeal an adverse determination
    • Providers and members can use the appeals process outlined in the Notice of Action letter.

How we communicate 


We notify our members and providers of updates to medical pharmaceutical procedures via:


  • Mail
  • Fax
  • Email
  • Our website
  • Member newsletters


Coverage decisions

Coverage decisions

At least once a year, we review and update medical pharmacy management procedures and medical pharmaceutical codes as determined by our Utilization Management Steering Committee (UMSC). The UMSC is comprised of senior and plan medical directors representing a broad range of specialties such as emergency medicine, behavioral health, pediatrics, surgery, family medicine, internal medicine and pharmacy.


Want the latest medical pharmacy procedures and codes? You can check our Provider Prior Authorization Requirement Search Tool, ProPAT.

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