Part D, coverage decisions & appeals

Members’ benefits include coverage for many drugs, most of which fall under Medicare Part D. Some drugs not covered by Medicare Part D may be covered by Illinois Medicaid. For drugs covered only by Medicaid, refer to Chapter 9, Section E of the Member Handbook. To be covered, a drug must be used for a medically accepted indication, meaning it is approved by the FDA or supported by recognized medical references.

Providers may request a coverage decision for a Medicare Part D drug. These requests can involve formulary exceptions, such as asking for coverage of a drug not on the plan’s formulary or requesting removal of restrictions like prior authorization or quantity limits. Providers may also seek coverage determinations to confirm whether a specific drug is covered for a patient, or submit payment requests for reimbursement of drugs already dispensed and paid for by the patient. If a pharmacy cannot fill a prescription as written, it will provide a written notice with instructions for requesting a coverage decision. If you or your patient disagree with a coverage decision, you have the right to appeal.

To request a coverage decision or exception, providers, patients, or authorized representatives can contact us by phone at 1-866-600-2139 (TTY: 711) or submit a written request by mail or fax. Include the patient’s name, contact information, and details about the drug and request. Written permission from the patient is not required for providers to submit a request. If someone other than the provider will act as the patient’s representative, instructions for appointing a representative are in Section E3 of the Member Handbook. When requesting an exception, providers must submit a supporting statement explaining the medical necessity of the drug and why alternatives are not appropriate. This statement can be sent by fax, mail, or phone with follow-up documentation.

If waiting for a standard decision could harm the patient’s health, providers may request a fast (expedited) coverage decision. Fast decisions are made within 24 hours, while standard decisions take up to 72 hours. Fast decisions apply only to drugs not yet received and require prescriber support. If a fast request is denied, we will send a letter explaining the reason and how to file a fast complaint, which will be reviewed within 24 hours. For reimbursement requests, we respond within 14 days and issue payment if approved. If we miss any required deadline, the case is automatically forwarded to Level 2 for review by an Independent Review Organization (IRO).

If a coverage decision is denied, an appeal can be filed within 65 days of the denial letter. Appeals may be submitted by phone, fax, or mail to:

Aetna Better Health Premier Plan MMAI
Part D Appeals Pharmacy Department
4750 S 44th PL STE 150
Phoenix, AZ 85040-4015

Include the patient’s details and any supporting medical information. Fast appeals follow the same criteria as fast coverage decisions and are decided within 72 hours. Standard appeals for drugs not yet received are resolved within 7 days, and reimbursement appeals within 14 days. If deadlines are missed, cases are forwarded to the IRO. Approved appeals result in coverage or payment within required timeframes.

If a Level 1 appeal is denied, the patient or representative may file a Level 2 appeal with the IRO, which independently reviews the case. Instructions for filing are included in the denial letter. Fast Level 2 appeals are decided within 72 hours, and standard appeals within 7 days for drugs not yet received or 14 days for reimbursement. If approved, coverage or payment is provided promptly. If denied, the patient may proceed to Level 3 if the dollar amount meets the threshold. Further levels involve review by an Administrative Law Judge and other entities, as outlined in Section J of the Member Handbook.

Patients may appoint a representative, such as a friend, relative, lawyer, or provider, by completing an Appointment of Representative (AOR) form available on the CMS website or by calling Member Services. The form must be signed by both the enrollee and the representative and is valid for one year unless a shorter timeframe is requested. If the representative is the prescribing provider or holds power of attorney, the form is not required.