Member handbook quick reference
Aetna Better Health of Michigan regularly updates its Member Handbook and Certificate of Coverage (COC). The Handbook and COC are available on this website. The Handbook and COC includes but are not limited to the following information:
Benefits and services included in, and excluded from, coverage
Aetna Better Health of Michigan covers the following services. We will cover these services if they are medically needed. Medically needed services include the tests you need to find out if you are ill or injured, the medical care to treat you if you are ill or injured, and the preventive care to help you avoid becoming ill or injured.
Medically needed services must:
- Be appropriate
- Meet your basic health care needs
- Be given to you in an appropriate and cost–effective way
- Be the services that medical research and science guidelines recommend
- Be used to treat your health condition
- Not be experimental
See your Certificate of Coverage for details on these benefits:
- Allergy testing, evaluations and injections including serum cost
- Ambulance and other emergency medical transportation
- Ambulatory surgical services and supplies
- Breast Cancer screening
- Breast Pumps for personal use
- Certified nurse midwife services
- Certified pediatric and family nurse practitioner services
- Chiropractic services
- Communicable disease services from local health department
- Contraceptive medications and devices
- Diabetic supplies
- Diagnostic lab, x-ray and other imaging services
- Doctor’s office visits
- Durable medical equipment and supplies
- Emergency services
- End Stage Renal Disease services
- Family planning services*
- Health education
- Health maintenance and preventive care
- Hearing services
- Home Health Services
- Hospice services (if requested by the member)
- Immunizations (shots)*
- Inpatient and outpatient hospital services (including consultations)
- Intermittent or short-term restorative or rehabilitative services (in nursing facility), up to 45 days per year
- Maternity and Newborn care
- Mental/Behavioral health care: maximum of 20 outpatient visits per calendar year
- Oral surgery
- Orthognathic surgery
- Out-of-state services authorized by the Plan
- Outpatient prescription drugs
- Over the counter drugs and supplies
- Pain Management services
- Parenting and Birthing classes
- Pharmacy services
- Podiatry services
- Prosthetics & orthotics/ support devices
- Radiology examinations and laboratory procedures
- Reconstructive surgery
- Short-term rehabilitative therapy
- Skilled nursing facility
- Temporomandibular Joint syndrome (TMJS)
- Therapeutic services (speech, physical, occupational)
- Tobacco cessation including pharmaceutical and behavioral support
- Transplant services
- Transportation for medically needed covered services
- Treatment for sexually transmitted diseases (STD)*
- Vision services
- Weight loss services
*No prior authorization required
To learn more about your benefits and limits, just call Member Services at 1-866-316-3784, TTY 711.
You’ll find a more detailed description of some of your benefits below. Review your Certificate of Coverage for more details on benefits, limits and exclusions.
Services not covered by Aetna Better Health of Michigan
- Any health care provided outside of the service area and not authorized by the Plan (except Emergency services)
- Cosmetic services and surgery
- Dental Services
- Elective termination of pregnancy (abortion) and related services (see Certificate of Coverage for more information)
- Fees, costs and expenses incurred by a person who donates an organ or tissue (unless the recipient is a Plan
Member and the donor’s health plan does not cover the expenses)
- Infertility treatment or related services
- Long term rehabilitative treatment
- Personal comfort items such as telephone, television and similar items
- Testing to determine parentage or DNA testing
- Private duty nursing services in the home
Services prohibited or excluded under Medicaid:
- Elective abortions and related services (see Certificate of Coverage for more information)
- Experimental/Investigational drugs, procedures or equipment
- Elective cosmetic surgery
- Treatment of infertility
Other exclusions are listed in the Certificate of Coverage (COC)
If you have questions on whether a procedure is covered, talk with your PCP or call Member Services at
1-866-316-3784, TTY 711.
Pharmaceutical management procedures
Prescription drugs are often an important part of your health care. As an Aetna Better Health of Michigan member, you have the right to certain prescription drug benefits.
Aetna Better Health of Michigan covers prescription drugs and certain over – the – counter drugs when presented with a prescription at a pharmacy.
To find out it if a drug that you take is covered, you can check our formulary. A formulary is a list of drugs that Aetna Better Health covers. The formulary is available on our website at www.aetnabetterhealth.com/michigan. You can use the prescription drug search tool to find out if a drug is covered. You may also request a printed copy of this formulary by calling Member Services. If you have any questions about a drug that is not listed, please call Member Services toll-free at 1-866-316-3784 (TTY 711), 24 hours a day, 7 days a week.
If a drug is not listed on the formulary, a Pharmacy Prior Authorization Request form must be completed. Your doctor will complete this form. They must show why a formulary drug will not work for you. They must include any medical records needed for the request.
The Pharmacy Prior Authorization form is available on our website. Your doctor may make a request by telephone at 1-866-316-3784 or via fax 1-855-799-2551.
Aetna Better Health of Michigan Members must have their prescriptions filled at an in-network pharmacy to have their prescriptions covered at no cost to them. You may go to our website to search for an in-network pharmacy near your zip code.
Prior authorization process:
Aetna Better Health of Michigan’s pharmacy prior authorization (PA) process is designed to approve drugs that are medically needed. We require doctors to obtain a PA before prescribing or giving out the following:
- Injectable drugs provided by a pharmacy
- Non-formulary drugs that are not excluded under a State’s Medicaid program
- Prescriptions that do not follow our guidelines (like quantity limits, age limits or step therapy)
- Brand name drugs, when a generic is available
Aetna Better Health of Michigan’s Medical Director decides if a drug is denied or approved using our guidelines. The Medical Director may need additional information before making a decision. This information may include the following:
- Drugs on the formulary have been tried and do not work (i.e. step therapy)
- No other drugs on the formulary would work as well as the drug requested
- The request is acceptable by the Federal Drug Administration (FDA) or is accepted by nationally noted experts
- For brand name drug requests, a completed FDA MedWatch form documenting failure or issues with the generic equal is required.
Both parties will be told of the decision through the telephone or mail.
Aetna Better Health of Michigan will fill prescriptions for a seventy-two (72) hour supply if the member is waiting for a decision by the Plan.
Step therapy and quantity limits:
The step therapy program requires certain drugs, such as generic drugs or formulary brand drugs to be prescribed before a specific second-line drugs is approved. Drugs having step therapy are listed on the formulary with “STEP”. Certain drugs on the Aetna Better Health of Michigan formulary have quantity limits and are listed on the formulary with “QLL”
The QLLs are based on FDA-approved doses and on nationally noted guidelines.
Your doctor can request an override step therapy and/or a quantity limit. They can fax a Pharmacy Prior Authorization Request form with medical records to 1-855-799-2551.
CVS Caremark Specialty Pharmacy:
Some drugs are considered Specialty drugs. They treat conditions, such as cancer, multiple sclerosis, and rheumatoid arthritis. Specialty drugs may not be available in your local pharmacy. A prior authorization is needed before they can be filled and delivered. Your doctor can call 1-866-316-3784 to request prior authorization, or complete the prior authorization form found on our website at, www.aetnabetterheath.com/Michigan or fax to 1-855-799-2551.
Specialty drugs can be delivered to the provider’s office, Member’s home, or other location as requested.
Mail order prescriptions:
Aetna Better Health of Michigan offers mail order prescription services through CVS Caremark. Use one of the following to request this service:
- Call CVS Caremark, toll free at 1-800-552-8159/TTY 711, Monday to Friday between 8 a.m. and 8 p.m., for help to sign up for mail order service. CVS Caremark will call the prescribing provider to get the prescription with the member’s ok.
- Go online:
- Log in and sign up for mail service online. If the member gives an ok, CVS Caremark will call the prescribing provider to get the prescription.
- By requesting your doctor to write a prescription for a 90-day supply with up to one year of refills. CVS Caremark will mail a mail service order form. When the member receives the form, the member fills it out and mails CVS Caremark the prescription and the order form. Forms should be mailed to:
PO BOX 94467
PALATINE, IL 60094-4467
Co-payments and other charges for which members are responsible
As an Aetna Better Health of Michigan member, you will not have any copays or deductibles with your benefits.
Aetna Better Health will pay for all of your covered services.
There are no copayments, deductibles or any other out of pocket cost for covered services. You should not sign any paperwork or agree to pay for any services that are covered by the health plan.
If you ask for or receive any services that are not covered through Aetna Better Heath, you may have to pay for them yourself.
Benefit restrictions that apply to services received outside company’s system or service area
If you need to see a doctor that is not in our network, Aetna Better Health of Michigan must approve it first. Your PCP will work with the Plan to make sure you get this care. Members who qualify for Medicaid due to pregnancy will be allowed access to out of network obstetrical and gynecological services without authorization if the member has an established relationship with that provider. These members will also be allowed access to out of network facilities without authorization for routine obstetrical and gynecological services if referred by the out of network obstetrician-gynecologist.
How to get language assistance
If you do not speak or understand English, call 1-866-316-3784 to ask for help. We will get you an interpreter when needed. All Interpreter services are free.
How to submit a claim for covered services, if applicable
As an Aetna Better Health of Michigan member, Aetna Better Health will pay for all of your covered services.
Let Aetna Better Health know if you receive a bill for your care of any covered services. Call Member Services at 1-866-316-3784, TTY 711, or send the bills to Aetna Better Health right away. Do not throw it away or ignore it. Let us know if you actually received the services listed on the bill; also include a brief description of the service. Don’t forget to give us a phone number; we may need to contact you if we have any questions.
Aetna Better Health of MI
Attn: Member Services
28588 Northwestern Hwy, Suite 380B
Southfield, MI 48034
How to get information about practitioners who participate in the company
If you need a free provider directory, we can mail you one. You can also go to our website for a provider list. For the most up-to-date information, just visit our website and select “Find a Provider.” Any questions just call Member Services at 1-866-316-3784, TTY 711. You can also get the following information about our providers: License information, Qualifications and Education.
How to get primary care services, including points of access
Your PCP is the health care provider who takes care of all your health needs. When possible, they’re the first person you should contact if you need health care. You’ll need to choose a PCP as soon as you join our plan.
Your PCP will see you for well care checkups and medical problems. Your PCP is your medical home. Having a medical home helps make sure the right medical care is available when you need it. Get to know your PCP. If you have a new PCP, call and make an appointment, even if you are not sick. Your PCP will learn about your overall health, this will help him prevent future illness. You’ll find a list of PCPs in our Provider Directory. You can ask Member Services for a list or search for providers on our website. Just select “Find a Provider” at the top of any page. You can choose one of the following provider types as your PCP:
- General Practice doctor
- Family Practice doctor
- Internal Medicine doctor
- OB/GYN doctor
- Nurse Practitioner
If you have a chronic health condition like diabetes or end stage renal disease (ESRD), you may need a specialist to take care of you as your PCP. Member Services can help you with this decision. Just call 1-866-316-3784, TTY 711.
You may also get services from a Federal Qualified Health Center (FQHC), a Rural Health Center (RHC) or at Tribal Health Center (THC) for primary care. These centers can be in or out of our network.
You may also get services from Child and Adolescent Health Centers (CAHCPs) and local health departments without prior authorization from the plan. See your Certificate of Coverage for more details regarding these services.
When you select Aetna Better Health of Michigan, you must have an in-network PCP. You may choose your PCP. If you do not, one is chosen for you. Your PCP will manage your health care needs. You may change your PCP
at any time for any reason. You can also do this online through the Member Web Portal. Most changes will take effect on the first of the next month.
Your PCP will help you get the health care services you needs.
How to get specialty care and behavioral healthcare services and hospital services
If you need to see a specialist your Primary Care Provider (PCP) will arrange for these services for you. Your PCP is the best person to help you locate the right specialist for your needs. If you need to see an OB/GYN, you can choose one from our provider list and go on your own. You will not need a referral or approval to see an OB/ GYN, certified nurse midwife, certified nurse practitioner, certified family nurse practitioner, certified pediatric nurse practitioner or a Pediatrician. You can get regular OB/GYN care without seeing your PCP first. If you need to see a doctor that is not in our network, Aetna Better Health of Michigan must approve it first. Your PCP will work with the Plan to make sure you get this care.
Other medical services, equipment and supplies may require an authorization by Aetna Better Health. If you have questions on what services require authorization, you can call Member Services at 1-866-316-3784, TTY 711.
Tell your PCP when you are receiving care from any other doctors. You may get a list of our specialists from Member Services at 1-866-316-3784, TTY 711. You can also find them on our website.
Aetna Better Health of Michigan covers 20 outpatient visits for behavioral health services. You can call Behavioral Health Services at 1-866-827-8704. You do not need to call your primary care doctor to get behavioral health services. If you have a serious behavioral health illness, you may be referred to the community mental Health Program in your county. If you’d like more information, just call Member Services at 1-866-316-3784, TTY 711.
All hospital services, except emergency care, must be approved or arranged by your PCP or Aetna Better Health. There may be some exceptions. Call Member Services if you have questions about a hospital stay or visit.
How to get care after normal office hours
For non-emergency care after normal business hours, you should call your PCP. Your PCP will provide instructions for getting the care you needs. If you cannot reach the PCP, our 24-Nurse Hour Nurse line can help you. Urgent care clinics are places you can go when you cannot see your PCP. They treat conditions that need immediate attention. These conditions are not life threatening. You should not use urgent care clinics for routine care. You should schedule routine care with your PCP.
How to get emergency care, including the company’s policy on when to directly access emergency care or use 911 services
Aetna Better Health of Michigan will cover all emergency services without prior approval when a person believes they have an emergency.
You should get emergency care when you have severe pain or a serious illness or injury that will cause death or disability if not treated at once.
- Chest pains or heart attack
- Choking or breathing problems
- A lot of bleeding or bleeding that will not stop
- Broken bones
Call 911 or go to the nearest hospital emergency department for care
How to get care and coverage when subscribers are out of the company’s service area
If you are out of town and have a medical emergency or need urgent care, go to the nearest urgent care center or emergency department for care. The hospital or urgent care center may call Aetna Better Health of Michigan for authorization to treat you. Remember to make an appointment with your PCP after all emergency or urgent care visits. Call member services at 1-866-316-3784 TTY 711 if you have questions about non-urgent coverage outside the company’s service area.
How to voice a compliant
We want to keep our members happy. We know there are times when members have questions or concerns about the service that they receive. When this happens, feel free to call Member Services at 1-866-316-3784 TTY 711. We will try to clear up any concerns as quickly as possible. If you’re still not happy, we have procedures for addressing your concerns. For a more complete explanation of the grievance and appeal process, please see Section 10 of the Certificate of Coverage. You may also call Member Services at 1-866-316-3784, TTY 711 or visit our website.
How to appeal a decision that adversely affects coverage, benefits or a member’s relationship with the company
A grievance may occur when you are upset about the quality, availability, or delivery of services that you received. You may file an appeal if Member Services does not resolve your grievance or you are not happy with the decisions covering or paying for services. It is your right to ask us to investigate your concern or to review our decision.
You can mail or deliver your grievance/appeal to:
Aetna Better Health of MI
ATTN: Appeals Coordinator
PO Box 81139
5801 Postal Road
Cleveland, OH 44181
1-866-316-3784, TTY 711
If you send your grievance/appeal to us in writing, we will send you a letter within three days of receiving your grievance/appeal letting you know we have it. Our staff reviewing your grievance/appeal will not have been previously involved in any prior decisions about your grievance/appeal. Aetna Better Health will make sure that the staff reviewing your grievance has the necessary qualifications to review your grievance/appeal.
When can I ask for a grievance/appeal?
You have 90 calendar days from the date that we made the decision that you are unhappy with. This may be the date on the “Adverse Action Notice” that you received. You can start the process by calling Member Services. However, you must follow up with a letter. If you need help filing your grievance/appeal, Member Services will help you. With your permission, someone else may ask for a grievance/appeal on your behalf. This person can be a friend, a relative, a doctor or an attorney. This person is called an Authorized Representative.
You can file an appeal before you have a service, if you already know that we will not cover or pay for the service. You can also file an Appeal after you have received a service and we have declined to cover it.
If you wish to present a grievance/appeal or to contact the Appeals Coordinator, you can call toll free at 1-866-316-3784, TTY 711.
For a more complete explanation of the grievance and appeal process, please see Section 10 of the Certificate of Coverage. You may also call Member Services at 1-866-316-3784, TTY 711 or visit our website.
How the company evaluates new technology for inclusion as a covered benefits.
Aetna Better Health reviews new technologies to see if they can be used for our members. Our doctors look at new treatments as they become available to see if they should be added to our benefit plan. Aetna Better Health reviews the services area listed below at least once a year:
- Medical services
- Behavioral Health services
- Medical Equipment
If you need a copy of the handbook and COC mailed to you, you may call our Customer Service Department at 1-866-316-3784, Monday through Friday, 8:00 a.m. to 5:00 pm. The TDD number is 1-866-318-3784.
Aetna Better Health wants to improve your heath and your family’s health. We look forwarding to servicing you and your family.