Part D prescription drugs

As a Medicare beneficiary, you have the right to certain prescription drug benefits. Medicare prescription drug benefits are also known as Part D. These benefits can help you pay for prescription drugs.

This section provides information about the prescription drug benefits covered by Aetna Better Health Premier Plan, including specialty drugs. This section also provides information about coverage limitations that may apply to some covered drugs.  You can also learn about our Medication Therapy Management Program and low-income subsidy.

Prescription drugs are often an important part of managing a health issue. For your peace of mind, it helps to know that a drug you take is paid for. You can find out by reading our formulary. A “formulary” is a list of drugs we cover and any costs you may have to pay.

Your Aetna Better Health Premier  Plan formulary is below. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. If you have any questions about a drug that is not listed, please call Member Services at 1‑866‑600-2139 (toll-free), 24 hours a day, 7 days a week. TTY Relay Illinois 711.

Find out if your medicine is covered
A formulary is a list of drugs covered by Aetna Better Health Premier Plan. It also is sometimes called a prescription drug list. Aetna Better Health Premier Plan consulted with team of health care providers to develop the formulary. It includes prescription therapies believed to be a necessary part of a quality treatment program.

Aetna Better Health Premier Plan generally covers the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Aetna Better Health Premier Plan network pharmacy, and other plan rules are followed.

View the 2019 Formulary Search Tool or the 2020 Formulary Search Tool

View Formulary List.

Contact us for the most recent list of drugs at 1‑866‑600-2139 (toll-free), 24 hours a day, 7 days a week. TTY Relay Illinois 7-1-1.

Can you ask for an exception to cover your drug?
Yes. You can ask AETNA BETTER HEALTH PREMIER PLAN to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on your drug.

• For example, AETNA BETTER HEALTH PREMIER PLAN may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more.

• Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.

How long does it take to get an exception?
First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours.

If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber’s supporting statement.

How can you ask for an exception?
To ask for an exception, call Member Services at 18666002139 (TTY/TDD 711), 24 hours a day, 7 days a week. A Member Services representative will work with you and your provider to help you ask for an exception.

View your 2019 Pharmacy Search Tool or 2020 Pharmacy Search Tool

Contact us for the most recent list of drugs at 1‑866‑600-2139 (toll-free), 24 hours a day, 7 days a week. TTY Relay Illinois 7-1-1.

For certain kinds of drugs, you can use the plan’s network mail-order services. Generally, the drugs available through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. The drugs that are available through the plan’s mail-order service are marked as “NM – Not available at Mail-order” on the formulary list.

Our plan’s mail-order service allows you to order up to a 90-day supply.

Download the Prescription Drug Mail-order Form English | Spanish here.

To get order forms and information about filling your prescriptions please call Aetna Better Health Premier Plan Member Services at 1-866-600-2139  (hearing impaired TTY/TDD 711) (24 hours a day, 7 days a week) to request a mail order form or you can register on line with CVS Caremark. Once registered, you will be able to order refills, renew your prescription and check the status of your order.

Ask your doctor to write a new prescription(s) for up to the maximum mail order day supply. Please be advised that our mail order pharmacy will call you to obtain consent before shipping or delivering any prescriptions you do not personally initiate.

Fill out the order form completely, including your member ID#, your doctor's name, medications you are taking and any allergies, illnesses or medical conditions you may have. Mail the order form and the prescription(s) to the address printed on the form. If there is no address on the form, you can mail it to: 

CVS/Caremark
PO BOX 94467
PALATINE, IL 60094-4467

When you order prescription drugs through the network mail-order pharmacy service, you must order no more than a 90-day supply of the drug. Generally, it takes CVS Caremark up to 21 days to process your order and ship it to you. However, please allow up to 21 days for the initial mail order fill.

Usually a mail-order pharmacy order will get to you in no more than 21 days. If a mail order is delayed by the mail order pharmacy 21 days or more, you will be contacted and told about the delay. If you have not received an order within 21 calendar days of when you sent the order, call CVS Caremark Customer Care at 1-800-552-8159 (hearing impaired only, TTY 1-800-231-4403) and they will begin processing a replacement order. The order will be quickly sent to you. Calls to this number are free.

Prescription Mail-order Form EnglishSpanish

Aetna Better Health Premier Plan requires you (or your physician) to get prior authorization for some drugs. This means that you need to get approval from Aetna Better Health Premier Plan before you fill your prescriptions. If you don’t, Aetna Better Health Plan may not cover the drug. Learn more about Prior Authorization Criteria.

Download the Prior Authorization Form 

Download the Hospice Exception Form for Medicare Part D plans.

Visit the 2019 online formulary tool or the 2020 Formulary Search Tool. Contact us for the most recent list of drugs at 1‑866‑600-2139 (toll-free), 24 hours a day, 7 days a week. TTY Relay Illinois 7-1-1.

Sometimes Aetna Better Health Premier Plan needs you first to try certain drugs to treat your medical condition before it covers another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Aetna Better Health Premier Plan may not cover Drug B unless you try Drug A first. If Drug A does not work, Aetna Better Health Premier Plan then covers Drug B. Learn more about Step Therapy Criteria.

Visit the 2019 online formulary tool or the 2020 formulary search tool. Contact us for the most recent list of drugs at 1‑866‑600-2139 (toll-free), 24 hours a day, 7 days a week. TTY Relay Illinois 7-1-1.

Find out if your medicine is covered
A formulary is a list of drugs covered by Aetna Better Health Premier Plan. It also is sometimes called a prescription drug list. Aetna Better Health Premier Plan consulted with team of health care providers to develop the formulary. It includes prescription therapies believed to be a necessary part of a quality treatment program.

Aetna Better Health Premier Plan generally covers the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Aetna Better Health Premier Plan network pharmacy, and other plan rules are followed.

View 2019 Aetna Better Health Premier Plan Prescription Drug Search Tool or the 2020 Aetna Better Health Premier Plan Prescription Drug Search Tool

View the Formulary List.

Contact us for the most recent list of drugs at 1‑866‑600-2139 (toll-free), 24 hours a day, 7 days a week. TTY Relay Illinois 711.

When you join Aetna Better Health Premier Plan, you may find you have different benefits. You also may have different drug coverage. We want to make your plan transition easy for you.

If Aetna Better Health Premier Plan does not cover a prescription drug you are taking before joining the plan, you may be able to get up to a 30-day supply at retail or up to 31 days-supply if you reside at a long-term care facility. This is called “Transition of Care,” (TOC) process. Transition of Care will be provided during the first 90 days of your enrollment if you are a new member to the Plan or the first 90 days of the new plan year starting January 1st if you are an existing member with continued coverage. This is called the “Transition Period.”

With Transition of Care, if your prescription is written for less than the maximum Transition of Care supply, the pharmacy will fill the prescription as written by your doctor until you receive up to a 30-day supply at retail or a 31-day supply at long-term care facility during your Transition Period.

Transition of Care will give you the opportunity to work with your doctor to find a new treatment plan and avoid disruption. If you receive a transition fill for a drug, we will send you a letter explaining that the drug was filled under the Transition of Care process. The letter will explain the action you can take to get approval for the drug or how to switch to another drug on the plan formulary.

Right to Transition Fill

New and renewing members in our Plan will be equally treated as new participants for Transition of Care at the beginning of the plan year.

New Members: If you are a new member and are taking a drug that is not on the Aetna Better Health Premier Plan’s formulary (List of Covered Drugs), or is subject to a prior authorization, step therapy, or quantity limitation, you can receive up to a 30-day supply of the Part D drug at retail or up to a 31-day supply at long-term care facility within the first 90-days of your enrollment date. If your prescription is written for less than the maximum Transition of Care supply, you can get it refilled, up to a 30-day supply at retail or a 31-day supply at long term care facility.

Renewing Members: Renewing members also get Transition of Care at the beginning of each plan year starting January 1st. If you are taking a Part D drug that was removed from the formulary, or the drug has a new prior authorization, step therapy, or quantity limitation at the beginning of the plan year, you can get up to a 30-day supply of medication at retail (or 31-day supply at long-term care) during the first 90 days of the new plan year. If your prescription is written for less than the maximum Transition of Care supply, you can get it refilled, up to a 30-day supply at retail or a 31-day supply at long term care facility.

If your doctor and you decide you need to continue on the drug that is not covered on the formulary or have coverage rules like prior authorization or quantity limitation, a Coverage Determination review can be requested by you, your appointed representative, or your doctor.

New and renewing members of the Aetna Better Health Premier Plan may ask for a Coverage Determination and Exception Request by calling Member Services at 1-866-600-2139 (TTY/TDD: 711), 24 hours a day, 7 days a week.

In general, we will determine your right to a Transition of Care supply. In some situations, we will need to get additional information from your doctor before we can determine if you are entitled to a Transition of Care fill.

You may also be eligible to receive a transition fill outside of your 90-day transition period. For example, you may be eligible to receive a temporary supply of a drug if you experience a change in your “level of care” (i.e., if you have returned home from a stay in the hospital with a prescription for a drug that isn’t on the formulary). There are other situations where you may be entitled to receive a temporary supply of a prescription drug.

It is important that you understand that the transition fill is temporary supply of this drug. Before this supply ends, you should speak to our Plan and/or your physician regarding whether you should change the drug(s) you are currently taking, or request an exception from our Plan to continue coverage of the drug. You, your authorized representative or your provider can ask for an exception request.

Coverage Determination and Exception Request form

Formulary (for a complete listing of covered drugs)

If you have questions about whether you are entitled to a temporary supply of a drug in a particular situation, please call Member Services at 1-866-600-2139 (TTY/TDD: 711), 24 hours a day, 7 days a week.

Medication Therapy Management Program

The Aetna Better Health Premier Plan medication therapy management program helps you get the greatest health benefit from your medications by:

  • Preventing or reducing drug-related risks
  • Increasing your awareness
  • Supporting good habits

 Who qualifies for the program?

We will automatically enroll you in the Aetna Better Health Premier Plan program at no cost to you if all three conditions apply:

  1. You take eight or more Medicare Part D covered maintenance drugs, and
  2. You have three or more of these long-term health conditions:
  • Asthma
  • Chronic obstructive pulmonary disease
  • Diabetes
  • Depression
  • Osteoporosis
  • Chronic heart failure
  • HIV
  • Cardiovascular disorders such as high blood pressure, high cholesterol or coronary artery disease, and

3. You reach $4,044 in yearly prescription drug costs paid by you and the plan.

Your participation is voluntary, and does not affect your coverage. The program is no cost to you and is open only to those who are invited to participate. The program is not a benefit for all plan members.

What services are included in the program?

The program provides you with a:

  • Comprehensive medication review and a
  • Targeted medication review

Comprehensive Medication Review

The review is a one-on-one discussion with a pharmacist, to answer questions and address concerns you have about the medications you take, including:

    • Prescription drugs
    • Over-the-counter (OTC) medicines
    • Herbal therapies
    • Dietary supplements and vitamins

The pharmacist will offer ways to manage your conditions with the medications you take. If more information is needed, the pharmacist may contact your prescribing doctor. The review takes about 30 minutes and is usually offered once each year—if you qualify. At the end of your discussion, the pharmacist will provide you a Personal Medication List with the medications you discussed during your review.

You will also receive a Medication Action Plan. Your plan may include suggestions from the pharmacist for you and your doctor to discuss during your next doctor visit.

Here is a blank copy of the Personal Medication List for tracking your prescriptions:

Targeted Medication Review

With this review, we mail, fax or call your doctor with suggestions about prescription drugs that may be safer, or work better than your current drugs. As always, your prescribing doctor will decide whether to consider our suggestions. Your prescription drugs will not change unless you and your doctor decide to change them. We may also contact you, by mail or phone, with suggestions about your medications.

How will I know if I qualify for the program?

If you qualify, we will mail you a letter. Also, you may receive a call, inviting you to participate in this one-on-one medication review.

Who will contact me about the review?

You may receive a call from a pharmacy where you recently filled one or more of your prescriptions. You will be given the option to choose an in-person review or a phone review.

You may be contacted by a call center pharmacist to provide your review, and ensure that you have access to the service if you want to participate. These reviews are conducted by phone.

Why is a review with a pharmacist important?

Different doctors may write prescriptions for you without knowing all the prescription drugs and/or OTC medications you take. For that reason, a pharmacist will:

  • Discuss how your prescription drugs and OTC medications may affect each other
  • Identify any prescription drugs and OTC medications that may cause side effects and offer suggestions to help
  • Help you get the most benefit from all of your prescription drugs and OTC medications
  • Review opportunities to help you reduce your prescription drug costs

How do I benefit from talking with a pharmacist? 

  • Discussing your medications can result in real peace of mind knowing that you are taking your prescription drugs and OTC medications safely
  • The pharmacy can look for ways to help you save money on your out-of-pocket prescription drug costs
  • You benefit by having a Personal Medication List and a Medication Action Plan to keep and share with your doctors and health care providers

How can I get more information about the program?

Please contact us if you would like additional information about our program, or if you do not want to participate after being enrolled in the program. Our number is 1-866-600-2139, 24 hours a day, 7 days a week. (TTY users, call 711.) The call is free.

Disenrollment
Disenrollment means that you are no longer a member of Aetna Better Health Premier Plan. If you are no longer a member, that means you cannot receive services from us.

These are the only two agencies that can enroll you or disenroll you.

  • Department of Healthcare and Family Services (HFS)
  • Illinois Client Enrollment Broker (ICEB)

Call the ICEB with questions at 1‑877‑912‑8880 or TTY 1‑866‑565‑8576.

Disenrollment for Cause
Under certain circumstances, Aetna Better Health Premier Plan can ask HFS to disenroll you from our health plan. This is called “disenrollment for cause.” Aetna Better Health Premier Plan can ask that you be disenrolled for cause for the following reasons.

  • You misuse the member ID card. In such cases, we will also report this to the Office of the Inspector General (OIG).
  • Your behavior is disruptive, unruly, abusive or uncooperative to the point that keeping you in our health plan seriously impairs our ability to give services to you or to other members.

An involuntary disenrollment request for member behavior must include proof that Aetna Better Health Premier Plan did the following things.

  • Gave the member at least one verbal warning and at least one written warning of what their actions or behavior may mean
  • Tried to educate the member regarding rights and responsibilities
  • Offered help through care management that would help the member to stop the behaviors
  • Determined that the member’s behavior is not related to the member’s medical or behavioral health

Aetna Better Health Premier Plan does not end your enrollment because your health gets worse, your health changes or because you use covered services.

We will not have you disenrolled for diminished mental capacity. We will not have you disenrolled for uncooperative or disruptive behavior caused by special needs (unless keeping you on our health plan seriously impairs Aetna Better Health Premier Plan’s ability to furnish covered services to you or other members). We will not have you disenrolled for exercising your appeal or grievance rights.

Please note: you will be disenrolled from Aetna Better Health Premier Plan if you move out of the service area. Aetna Better Health Premier Plan serves members in the following counties only:

  • Cook
  • DuPage
  • Kane
  • Will

Voluntary Disenrollment
Members can ask to leave the health plan with an oral or written request to either HFS or Aetna Better Health Premier Plan. Members can ask to leave the health plan for any the reasons below:

  • The member moves out of the covered area.
  • The member feels that Aetna Better Health Premier Plan does not cover the services they are seeking because of moral or religious conflict.
  • The member needs services to be done at the same time, but not all services are covered. The member’s doctor or another doctor believes that not getting the services together would put the member’s health care needs at risk.
  • A poor quality of care.
  • A lack of access to services covered under the contract.
  • There are limited doctors who know how to deal with the member’s health care needs.

LTC pharmacies are included in the network.  These pharmacies offer pharmacy services to patients that are housed in a type of group home like a Nursing home or Rehabilitation center.  Generally all LTC pharmacies are in network.  LTC pharmacies will fill prescription orders written by medical staff in the group home and deliver the medication directly to the medical staff who will distribute the medication to the members. Generally, each group home will have one or two LTC pharmacies that supply most of the pharmacy services to all of the members residing in the facility.

To get information about filling your prescriptions at an LTC Pharmacy please call Aetna Better Health Premier Plan Member Services at 1-866-600-2139 (TTY 711) 24 hours a day, 7 days a week.

Safe Use of Opioid Pain Medication – Information for Medicare Part D Patients

Prescription opioid pain medications—like oxycodone (OxyContin®), hydrocodone (Vicodin®), morphine, and codeine—can help treat pain after surgery or after an injury, but they carry serious risks, like addiction, overdose, and death. These risks increase with the higher the dose you take, or the longer you use these pain medications, even if you take them as prescribed. Your risks also increase if you take certain other medications, like benzodiazepines (commonly used for anxiety and sleep), or get opioids from many doctors and pharmacies.

Medicare is dedicated to helping you use prescription opioid pain medications more safely, and is introducing new policies for opioid prescriptions in the Medicare Part D prescription drug program beginning in January 2019.

Safety reviews when opioid prescriptions are filled at the pharmacy

Your Medicare drug plan and pharmacist will do safety reviews of your opioid pain medications when you fill a prescription. These reviews are especially important if you have more than one doctor who prescribes these drugs. In some cases, the Medicare drug plan or pharmacist may need to first talk to your doctor.

Your drug plan or pharmacist may do a safety review for:

  • Potentially unsafe opioid amounts.
  • If you take opioids with benzodiazepines like Xanax®, Valium®, and Klonopin®.
  • New opioid use—you may be limited to a 7-day supply or less. This does not apply to you if you already take opioids.

If your pharmacy can’t fill your prescription as written, including the full amount on the prescription, the pharmacist will give you a notice explaining how you or your doctor can contact the plan to ask for a coverage decision. If your health requires it, you can ask the plan for a fast coverage decision. You may also ask your plan for an exception to its rules before you go to the pharmacy, so you’ll know if your plan will cover the medication.

Drug Management Programs (DMPs)

Starting January 1, 2019, some Medicare drug plans (Part D) will have a DMP. If you get opioids from multiple doctors or pharmacies, your plan may talk with your doctors to make sure you need these medications and that you’re using them safely.

If your Medicare drug plan decides your use of prescription opioids and benzodiazepines isn’t safe, the plan may limit your coverage of these drugs. For example, under its DMP your plan may require you to get these medications only from certain doctors or pharmacies to better coordinate your health care.

Before your Medicare drug plan places you in its DMP, it will notify you by letter. You’ll be able to tell the plan which doctors or pharmacies you prefer to use to get your prescription opioids and benzodiazepines. After you’ve had the opportunity to respond, if your plan decides to limit your coverage for these medications, it will send you another letter confirming its decision. You and your doctor can appeal if you disagree with your plan’s decision or think the plan made a mistake. The second letter will tell you how to contact your plan to make an appeal.

Note: The safety reviews and DMPs should not apply to you if you have cancer, get hospice, palliative, or end-of-life care, or if you live in a long-term care facility.

Talk with your doctor

Talk with your doctor about all your pain treatment options including whether taking an opioid medication is right for you. There might be other medications you can take or other things you can do to help manage your pain with less risk. What works best can be different for each patient. Treatment decisions to start, stop or reduce prescription opioids are individualized and should be made by you and your doctor. For more information on safe and effective pain management, visit CDC.gov/drugoverdose/patients.

Additional Resources

Please contact Member Services at 1-866-600-2139 (TTY: 711) for additional information.

Other resources include:

Home infusion pharmacies are included in the network. These pharmacies supply drugs that may need to be given to you by an intravenous route or other non-oral routes, such as intramuscular injections, in your home.

To get information about filling your prescriptions at a Home Infusion Pharmacy please call Aetna Better Health Premier Plan Member Services at 1-866-600-2139 (TTY: 711) 24 hours a day, 7 days a week.