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Outpatient medications
Questions about a member’s pharmacy benefits or a specific medication?
For Medicaid:
Contact the 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.
For CHIP:
Contact Express Scripts at 1-855-230-7778 or see a copy of the Express Scripts preferred drug list (PDL) (PDF).
Note: Starting July 1, 2024, CHIP members will transition to Gainwell Technologies as their point of contact.
Medical pharmaceuticals
Questions about medications a member receives in a provider’s office, hospital, inpatient facility, ambulatory care center, or in the home?
Call our Utilization Management department at 1-844-835-4930 (TTY: 711).
Medical pharmaceutical management (MPM) and coverage decisions
Medical pharmaceutical management (MPM) and coverage decisions
Our MPM procedures follow the same utilization management processes as requests for medical services using clinical criteria specific to medical pharmaceuticals. Need a copy of the criteria? Call us at 1-844-835-4930 (TTY: 711).
Our MPM procedures don’t include the development of an open or closed formulary or preferred drug list (PDL). However, to promote evidence-based and clinically appropriate drug use, the clinical criteria may include processes for these methods:
- Pharmaceutical classes
- Preferred pharmaceuticals
- Considerations for limiting access to drugs in certain classes
- Quantity level limits
- Therapeutic interchange
- Step therapy
- Other management methods
The criteria doesn’t include a tiered formulary system that would impact the cost to a member. It also doesn’t include:
- Generic substitution
- Automatic substitutions
- Incentives that apply to the use of certain pharmaceuticals
For medical pharmaceuticals — which are also available in point-of-sale form — we are required to follow the West Virginia Bureau for Medical Services (BMS) preferred drug list (PDL). We're not involved in developing this PDL but refer to it to make decisions within these instances.
Need to request an exception?
We don’t maintain a formulary or PDL, but you may request an exception to the clinical criteria. The exception must be based on medical necessity.
You can make a request in one of two ways:
- Include the exception request along with your original prior authorization request
- Call our Utilization Management department at 1-844-835-4930 (TTY: 711)
In your request, be sure to attach clinical documentation which may include:
- Evidence of an adverse reaction to a preferred medication
- Other clinical rationale to support the exception request
An Aetna Better Health pharmacist and/or medical director will review your exception request.
How we communicate
We notify our members and providers of updates to medical pharmaceutical procedures via:
- Fax
- Our website
- Member newsletters
- Provider workshops
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 Medicaid Medical Policy Committee (MMPC). The MMPC includes senior and plan medical directors representing a broad range of specialties, such as:
- Emergency medicine
- Behavioral health
- Pediatrics
- Surgery
- Family medicine
- Internal medicine
- Pharmacy
Want the latest medical pharmacy procedures and codes? You can check our Provider Prior Authorization Requirement Search Tool, ProPAT.
