Part D complaints, coverage decisions & appeals

You have rights if you have a problem or complaint about the pharmacy and medical care you receive. Learn more about the complaints, coverage decisions and appeals process for medical care below. You have the right to get information about appeals, complaints, and exceptions that other members have filed against our plan.  Call Member Services at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week.

See Non-Part-D for information on these processes for Medicare Part C benefits.

To speak with the Office of the Medicare Ombudsman (OMO) for help with a complaint, grievance or information request, visit the website of the Ombudsman on Medicare.gov.

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.

Complaints

You have the right to file a complaint if you have a problem or concern. The formal name for making a complaint is “filing a grievance.” A grievance is a complaint or dispute. The complaint process is used for certain types of problems only. The information you provide us will be held in confidence.

Please see the Evidence of Coverage - EnglishSpanish for detailed information and timelines for filing a grievance.

You may make a complaint if you have a problem with Aetna Better Health Premier Plan or one of our network providers or pharmacies. You may make a complaint if you have a problem with things such as:

Does include

  • Quality of care
  • Waiting too long to fill a prescription
  • Pharmacy errors such as dispensing the wrong medication or dosage
  • The way your pharmacist or other staff behave
  • Customer service
  • Access to network pharmacies
  • Being able to reach someone by telephone or get the information you need and complaints

Does not include

  • Coverage decision
  • Low-Income Subsidy (LIS) or Late-Enrollment Penalty (LEP) determination
  • Expressing dissatisfaction with any aspect of the operations, activities or behavior of a Part D plan sponsor, regardless of whether remedial action is requested

We may use your complaint type to track trends and identify service issues.

Whether you call or write, you should contact Member Services right away. You must make your complaint within 60 days after you have the problem you want to report.

  • Start by calling Member Services. We will let you know what you need to do.
    24 hours a day, 7 days a week
    1‑866‑600-2139

    Hearing Impaired (TTY: 711)
  • If you don’t want to call (or you called and were not satisfied), send your complaint to us in writing by mail for fax.

    Aetna Better Health Premier Plan
    7400 West Campus Rd.
    New Albany, OH 43054
    Fax: 1-855-883-9555

For more information on the total number of grievances, appeals and exceptions with the health plan please call Member Services at 1‑866‑600-2139, (TTY: 711), 24 hours a day, 7 days a week. 

If you write us, it means that we will use our formal procedure for answering complaint. Here's how it works:

  • If you ask for a written response, file a written complaint if related to quality of care, we will respond to you in writing.
  • If we cannot resolve your complaint over the phone, we will respond to your complaint within 30 calendar days.

You may file a request for a "fast complaint" (expedited grievance) if you disagree with our decision not to process your request for a "fast response" to a coverage decision or appeal.

If you have a complaint about your quality of care, you may make a complaint with the plan by calling Member Services at 1‑866-600-2139, (TTY: 711), 24 hours a day, 7 days a week. We will research the complaint and send a response to you.

You also may file a grievance with Illinois Quality Improvement Organization, Livanta:

Livanta
10820 Guilford Rd., Suite 202
Annapolis Junction, MD 20701

Toll-Free Phone: (888) 524-9900 
Toll-Free TTY: (888) 985-8775 

Website: www.livantaqio.com 

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: 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: 711), 24 hours a day, 7 days a week.

 

Request an exception to the Formulary and coverage decisions

You, your authorized representative or your doctor has the right to request a coverage decision or exception for a drug that you feel should be covered for you. Or to request we pay for a prescription drug you already bought.

If your pharmacist tells you your prescription drug claim was rejected, the pharmacist will give you a written notice explaining how to request a coverage determination or exception.

Aetna Better Health Premier Plan has a list of covered Part D prescription drugs called a formulary. Your network doctor will refer to the formulary and typically prescribe a drug from it to meet your medical needs. Not all prescription drugs are listed on our formulary. Some formulary prescription drugs may require prior authorization, step therapy or have quantity limits.

Aetna Better Health Premier Plan Formulary

This information is also explained in the Aetna Better Health Premier Plan Evidence of Coverage - English / Spanish.

When you, your authorized representative, or your doctor requests a coverage decision or exception, we will make the coverage decision (approval or denial) to provide or pay for a Medicare Part D prescription drug. We will review and process the request within the expedited (24 hours) or standard (72 hours) required by Medicare. 

You can make a request by phone, fax or mail. Or you can complete a coverage decision form. The request needs to include a supporting statement from your doctor to provide the medical reasons for the drug requested. Your doctor also can submit a coverage decision or exception request to Aetna Better Health. 

Coverage decision form
You can ask Member Services to mail you a coverage decision form. You can download and print it to send by mail or fax. Or you can submit it online.

Coverage Decision Form - submit online
Coverage Decision Form - Print

Call
Aetna Better Health Premier Plan Member Services
24 hours a day, 7 days a week
1‑866‑600-2139
Hearing Impaired (TTY: 711)

Fax
Aetna Better Health Premier Plan
Part D Coverage Determination
Pharmacy Department
1-855-365-8109

Write
Aetna Better Health Premier Plan
Part D Coverage Determination
Pharmacy Department
4500 E. Cotton Center Blvd
Phoenix, AZ 85040

 

 

If the decision is “yes” to cover part or all of what was requested, Aetna Better Health Preimer Plan will notify you and will provide the drug or payment.

If the decision is “no,” Aetna Better Health Premier Plan will notify you. You will receive a written notice explaining why it was denied and how you can appeal this decision. An unfavorable decision could be because the drug is not on the formulary, determined not to be medically necessary, or you have not tried a similar drug listed on the formulary. It could also be based on whether or not you have met the prior authorization requirement. In most situations, this process cannot be applied to any medications excluded

You have the right to a timely coverage decision (see table). If Aetna Better Health Premier Plan does not make a timely coverage decision, it is required to automatically forward your case file to the Independent Review Entity. You may file an expedited complaint if we do not notify you of our decision within this timeframe (see Grievances).

DESCRIPTION

STANDARD COVERAGE DECISION

EXPEDITED COVERAGE DECISION

Coverage decisions

Aetna Better Health Premier Plan will notify you of a decision as fast as your health condition requires, but not later than 72 hours from the receipt of the request.

Aetna Better Health Premier Plan will notify you of a decision as fast as your health condition requires, but not later than 24 hours from the receipt of the request.

Formulary exceptions

 

 

 

 

 

Upon receipt of your doctor’s supporting statement for a formulary exception request, Aetna Better Health Premier Plan will notify you as fast as your health condition requires but not later than 72 hours from the receipt of the request.

You will receive payment within 30 days.

Upon receipt of your doctor’s supporting statement for a formulary exception request, Aetna Better Health Premier Plan will notify you as fast as your health condition requires but not later than 24 hours from the receipt of the request.

 

Request for Payment

If you ask for a request to be reimbursed for a drug you paid for, Aetna Better Health Premier Plan will notify you or your authorized representative of its decision within 14 calendar days from the reciept of the request. If we determine in your favor, Aetna Better Health Premier Plan will make payment to you within 14 calendar days after we receive your request.

Appeals

If you receive a denial notice or a prescription drug, you have the right to file an appeal, also called a “redetermination” request.

Please see the Evidence of Coverage for more information about Part D prescription drug coverage decisions and appeals in the Aetna Better Health Premier Plan Evidence of Coverage - English / Spanish. To learn how many appeals and complaints Aetna Better Health Premier Plan has processed, please contact us at 1‑866‑600-2139, (TTY: 711), 24 hours a day, 7 days a week.

If you are notified of a coverage decision denial by Aetna Better Health Premier Plan, you or your appointed representative may submit a redetermination request (1st Level of Appeal). This needs to be done within 60 calendar days from the date of the written notice. You may submit an appeal after this timeframe if you have good cause.

You can make a request by phone, fax or in writing. Or you can complete a Redetermination Request form. The request needs to include a supporting statement from your doctor to provide the medical reasons for the drug requested. Your doctor also can submit a coverage Redetermination Form.

You may file a request for an expedited appeal for drug coverage if you believe that applying the standard appeals process could jeopardize your health. If Aetna Better Health Premier Plan decides that the timeframe for the standard process could seriously jeopardize your life, health or ability to regain maximum function, the review of your request will be expedited.

  1. You, your appointed representative, or your doctor or other prescriber can request an expedited appeal. An expedited request can be submitted orally or in writing to Aetna Better Health Premier Plan and your doctor or other prescriber may provide oral or written support for your request for an expedited appeal.
  2. Aetna Better Health Premier Plan must provide an expedited appeal if it determines that applying the standard timeframe for making a decision may seriously jeopardize your life or health or your ability to regain maximum function.
  3. A request made or supported by your doctor or other prescriber will be expedited if he/she tells us that applying the standard timeframe for making a decision may seriously jeopardize your life or health or your ability to regain maximum function.

How to submit an appeal or redetermination request
You can submit a redetermination request by phone, fax or mail. Or you can complete a coverage redetermination form online.

Coverage redetermination form
You can ask member services to mail you a coverage determination form. You can download and print it to send by mail or fax. Or, you can submit it online.

When you or your representative requests a redetermination, a special team will review your request. Then it will collect evidence and information from you or your doctors. The case then will be reviewed by a different physician than the one who made the original decision. Aetna Better Health Premier Plan will notify you and your doctor of the redetermination decision, following the timeframes below.

If Aetna Better Health Premier Plan fails to make a redetermination decision and notify you within the timeframe, Aetna Better Health Premier Plan must submit your redetermination case file to Independent Review Entity (IRE) for review. Aetna Better Health Premier Plan will notify you if this action should occur. You have the right to a timely redetermination (see Appeal Levels table). You may file an expedited complaint if we do not notify you of our decision within this timeframe (see Complaints).

If Aetna Better Health Premier Plan notifies you of an unfavorable decision, and you disagree, you may submit a reconsideration request (2nd Level Appeal) to the Independent Review Entity (IRE). Instructions will be in the written notice.

 Level

DESCRIPTION

STANDARD APPEAL

EXPEDITED APPEAL

1

Redetermination by Aetna Better Health Premier Plan

Upon receipt of your appeal (redetermination), the Appeals Unit Coordinator will gather evidence on the basis of the denial of the Part D prescription drug, and additional evidence from you or your representative and prescribing doctor.

Your appeal will be evaluated by a clinical expert.

Aetna Better Health Premier Plan will notify you by telephone as fast as your health condition requires but not later than 7 calendar days from the receipt of the appeal.

You or your doctor may request Aetna Better Health Premier Plan to expedite your appeal if it believes that waiting for the standard timeframe will cause you serious harm.  Aetna Better Health Premier Plan will notify you of the decision by telephone as fast as your health condition requires but not later than 72 hours after receipt of your appeal.  If Aetna Better Health Premier Plan does not agree that your appeal requires a fast review, you will be notified that the standard timeframe will be applied.

2

Reconsideration by Independent Review Entity (IRE)

If Aetna Better Health Premier Plan upholds the original denial for your prescription drug, you may send your appeal to the CMS-contracted Independent Review Entity (IRE) within 60 calendar days of the Aetna Better Health Premier Plan notice. The IRE will review your appeal and make a decision within 7 calendar days.

You may file a fast appeal with the IRE if you or your doctor believes that waiting for the standard timeframe will cause you serious harm. The IRE will review your appeal and notify you if they do not agree that your appeal requires a fast review, and will apply the standard timeframe. If the IRE agrees, they will notify you of their decision within 72 hours from the time your appeal was received.

3

Hearing with Administrative Law Judge (ALJ)

If the IRE decision is unfavorable and the amount in dispute meets the requirements, you may request a hearing with the ALJ. You must follow the instructions on the notice from the IRE.

Same as Standard Review

4

Review by Medicare Appeals Council (MAC)

If the ALJ decision is unfavorable, you may appeal to the MAC, which is within the Department of Health and Human Services. The MAC oversees the ALJ decisions.

Same as Standard Review

5

Federal District Judge

If you do not want to accept the decision, you might be able to continue to the next level of the review process. It depends on your situation. Whenever the reviewer says no to your appeal, the notice you get will tell you whether the rules allow you to go on to another level of appeal. If the rules allow you to go on, the written notice will also tell you who to contact and what to do next if you choose to continue with your appeal.

Same as Standard Review