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Pharmacy benefits
We cover a wide range of prescription and over-the-counter (OTC) medications to keep members as healthy as they can be.
Covered medications
Covered medications
Prescription medications
We cover the prescription medications on the preferred drug list (PDL) for STAR (Medicaid) members at no extra cost. Members of the Children’s Health Insurance Program (CHIP) may have to pay a small copay (usually $3 or less). If your patient needs medication, you’ll want to check the list for covered medications, quantity limits and updates.
If a medication isn’t listed on the PDL, you can:
- Prescribe a similar one that’s on the list
- Get prior authorization (PA) for coverage
The preferred glucose meter and test strips are Lifescan OneTouch® products. The preferred lancets and lancing devices are Lifescan OneTouch Delica® and Delica® Plus. The preferred pen needles are Beckton Dickson (BD) products. Non-preferred diabetic supplies require prior authorization (PA).
You can check drugs that need clinical PA.
*Please Note: Aetna Better Health of Texas does NOT require clinical PA for ADHD medications or antipsychotics. These drugs may still be subject to PDL PA requirements.
To Identify the following:
- Preferred and Non-Preferred Drugs
- Any preferred drug that can be substituted for non-preferred drugs; and
- Clinical prior authorizations
Visit https://online.epocrates.com/ and select Aetna Better Health of Texas STAR, Aetna Better Health of Texas STAR Kids, or Aetna Better Health of Texas CHIP
Aetna Better Health of Texas is pleased to offer Pyrls® for our providers, free of charge. All you need to do is log into your Availity portal and click on the Aetna Better Health Payer Space "Resources" tab. Pyrls® is a drug information database available on the web and via mobile application that provides clinicians and professional trainees with curated, evidence-based information to guide proper use of medication therapy.
Pyrls® platform features:
- 800+ clinical drug summaries
- Pharmacotherapy reviews
- Key patient counseling points
- VDP PDL integration
Still not sure if we cover a specific medication? Just contact us. We can check it for you.
The preferred glucose meter and test strips are Lifescan OneTouch® products. The preferred lancets and lancing devices are Lifescan OneTouch Delica® and Delica® Plus. Non-preferred diabetic supplies require prior authorization (PA).
Non-preferred diabetic supplies PA criteria (PDF)
We now cover mosquito repellents for the prevention of the Zika virus.
Learn more about the mosquito repellent benefit
Members can get coverage for OTC medications on the PDL when they:
- Meet any added requirements (for some medications)
- Get a prescription from their provider
- Fill their OTC prescription at a pharmacy in our network
Not sure what’s covered? Just contact us. Be sure to have the member’s list of medications ready. We can check to see if they’re on the list.
$25 for OTC products
Members can get $25 per month toward some OTC medications and supplies.
List of items for OTC benefit (PDF)
Specialty medications
Specialty medications
If you prescribe a specialty medication, members can fill it at any pharmacy in our network. Not all pharmacies carry these medications, so members may need to find a specialty pharmacy. Some conditions that need specialty medications include:
- Cancer
- Hemophilia
- Immune deficiency
- Multiple sclerosis
- Rheumatoid arthritis
You’ll want to get PA for these medications. Fax the PA form (PDF) to 1-844-275-1084. Or you can contact us to ask for PA. You can also include any medical records that may help with the review of your request.
More pharmacy info
Learn about everything from PA to durable medical equipment (DME).
If a member needs prior authorization (PA) for a medication, there are a few ways you can request PA:
- Complete the Texas standardized pharmacy PA form (PDF) on their behalf.
- Submit a request through electronic prior authorization (ePA).
- Clinical Prior Authorization criteria
- Contact us.
Visit the pharmacy PA page to learn more about how to request PA.
When members need medication, they’ll:
- Ask you to make sure the medication is on the PDL
- Take their prescription to a pharmacy in our network
- Show their plan member ID card at the pharmacy
Remind members to check with you at least five days before running out of medication. They understand that you may want to see them before prescribing refills.
In person
Members can fill prescriptions at any pharmacy in our network. We can’t cover medications that they fill at other pharmacies.
Electronically sending an accurate prescription to a pharmacy is called E-prescribing. You can submit both paper and electronic prescriptions. If you choose to prescribe medications electronically, you must do so in accordance with all applicable state and federal laws.
Members and providers can call CVS Caremark® at 1-855-271-6603 (TTY: 711), 24 hours a day, 7 days a week. They’ll explain which medications they can fill with CVS Caremark Mail Service Pharmacy. CVS Caremark will also contact you for a prescription and mail the member’s medication. Members can sign up for mail service:
Online
Members can log in to the Member Portal. Then, they’ll choose: Tasks, Pharmacy services, CVS and then Start mail service.
With an order form
Members will ask you to write a prescription for a 90-day supply with up to one year of refills. Then, they can fill out a mail service order form (English PDF) | (Spanish PDF). Or we can mail them a form. They just need to contact us.
Members can send the form, along with their prescription, to:
CVS Caremark
PO Box 2110
Pittsburgh, PA 15230-2110
During an emergency, members can receive a 72-hour supply of prescribed medication from their pharmacy when:
- The medication is non-preferred on the PDL or the medication needs PA
- The prescriber isn’t able to complete the PA
- They need the medicine right away
This process is only for emergencies, not routine use.
Some pharmacies can provide DME and medical supplies to Medicaid (STAR) and CHIP plan members. The Texas Medicaid (STAR) and CHIP programs cover these pharmacies. You can learn more about DME benefits and the pharmacies that take part.
The Vendor Drug Program may not cover all medically necessary medicines and supplies. In these cases, the Comprehensive Care Program (CCP) may be able to help. This is for members from birth through age 20. To find a CCP pharmacy provider, members can contact Texas Medicaid and Healthcare Partnership (TMHP). They can call 1-800-335-8957.
Check these links for more info on antibiotic stewardship:
Centers for Disease Prevention and Control (CDC):
- Core Elements of Antibiotic Stewardship
- Antibiotic Use in the United States, 2020 Update: Progress and Opportunities
National Library of Medicine:
With respect to Pharmacy Services provided to Texas Medicaid and CHIP enrollees, Caremark has provided Texas Medicaid and CHIP pharmacies with the following process for pharmacies to access MAC prices.
Pharmacy Portal Texas MAC Price Look Up
Medication recalls
Need info 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.
One Touch is a trademark of LifeScan IP Holdings, LLC.
CoverMyMeds is a trademark of CoverMyMeds, LLC.
Aetna Better Health® contracts with CVS Caremark to manage the pharmacy network.