Part D Complaints, Coverage Decisions & Appeals

You have rights if you have a problem or complaint about a pharmacy or about any medical care you receive. Below you can learn more about the complaints and appeals process, and how coverage decisions are made for medical care.

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

The Office of the Medicare Ombudsman (OMO) can help you if you have questions about the complaint grievance or appeal process. Just visit the website of the Ombudsman on Medicare.gov.

You have the right to get information about appeals, complaints, and exceptions that other members have filed against our plan.  Call Member Services at 1-855-676-5772 or TTY: 711 24 hours a day, 7 days a week.

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 Aetna Better HealthSM Premier Plan Member Handbook 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:

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 treat you
  • Customer service
  • Access to network pharmacies
  • Being able to reach someone by telephone or get the information you need

Part D complaints do not include:

  • A coverage decision
  • A 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 calendar days after you have the problem you want to report. 

Start by calling Member Services at 1-855-676-5772 (TTY: 711), 24 hours a day, 7 days a week. We’ll let you know what you need to do. If you don’t want to call (or you called and were not satisfied), send your complaint to us in writing by mail or fax to:

Aetna Better Health of Michigan

PO Box 81139
5801 Postal Road
Cleveland, OH 44181
Fax: 1-844-321-9567

For more information on the total number of grievances, appeals and exceptions with the health plan, please call Member Services at 1-855-676-5772 (TTY 711).

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

If you ask for a written response to a written complaint related to quality of care, we will respond to you in writing. If you don’t ask for a written response, we’ll call you. If we cannot resolve your complaint over the phone, we will respond to your complaint in writing 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 1-855-676-5772 (TTY 711). We’re here 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 the Quality Improvement Organization, Livanta:

Livanta
10820 Guilford., Suite 202
Annapolis Junction, MD 20701
Toll-Free Phone: 1-888-524-9900
Toll-Free TTY: 1-888-985-8775

Website: www.livantaqio.com

As a member of the Aetna Better HealthSM Premier Plan, 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 pay for a prescription drug you already bought.

If your pharmacist tells you that 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 HealthSM Premier Plan has a list of covered prescription drugs called a formulary. Your network doctor will refer to the formulary and typically prescribe a drug from the formulary that will meet your medical needs. Not all prescription drugs are listed on our formulary. Some formulary prescription drugs may require prior authorization, step therapy or quantity limits.

Aetna Better HealthSM Premier Plan Formulary

This information is also explained in the Aetna Better HealthSM Premier Plan Member Handbook.

CVS Caremark is a Pharmacy Benefit Manager (PBM) that Aetna Better Health Premier Plan has contracted with to administer the Aetna Better Health Premier Plan prescription drug benefit. A coverage decision is a decision (approval or denial) made by the health plan regarding whether to provide or pay for a prescription drug.

Aetna Better Health Premier Plan must review and process the request within the expedited (24 hours) or standard (72 hours) timeframes required by Medicare. You, your authorized representative or your doctor may ask for a coverage decision or exception.

Requests can be made in writing, by phone or by fax. Members can call Member Services at the number provided below to request a coverage decision or exception. You may also use the Request for Coverage Decision form to submit your request. Your doctor can also submit a coverage decision or exception request directly to Aetna Better Health.

Coverage decision form
Member Services can mail you a coverage decision form. Or, you can just download the form below. You can choose to print this form and send it to us by mail or fax or you can submit it online.

Request for Medicare Prescription Drug Coverage Determination form - download and print 

Call
Member Services
24 hours a day, 7 days a week
1-855-676-5772 (TTY 711)

Fax
1-844-242-0914

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

DESCRIPTION

 

 

STANDARD COVERAGE DECISION

 

 

EXPEDITED COVERAGE DECISION

 

Coverage decisions

 

 

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

 

 

Aetna Better Health 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 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 calendar days.

 

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

If the decision is “yes” to cover part or all of what was requested, we will notify you and send you the drug or payment. 

If the decision is “no,” we will notify you in writing. We will explain why it was denied and how you can appeal this decision. An unfavorable decision could be because the drug is not on the formulary or determined not to be medically necessary. Or, it may be because you haven’t tried a similar drug listed on the formulary. It could also be because you needed prior authorization for the drug. In most situations, this will not apply to any excluded medications, under state or federal law.

You have the right to a timely coverage decision (see table). If Aetna Better HealthSM Premier Plan does not make a timely coverage decision, we are 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).

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

Please see the Member Handbook for more information about Part D prescription drug coverage decisions and appeals.

To learn how many appeals and complaints Aetna Better HealthSM Premier Plan has processed, please contact us at 1-855-676-5772 (TTY 711). We’re here 24 hours a day, 7 days a week.

If you are notified of a coverage decision denial by Aetna Better HealthSM 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 coverage redetermination form online. The request needs to include a supporting statement from your doctor to provide the medical reasons for the drug requested. Your doctor can also submit a coverage decision or exception request to CVS Caremark.

Coverage redetermination form

Click the link below to submit the Coverage Redetermination form online.

Coverage Redetermination form - submit online

Phone
1-855-676-5772
(TTY: 711)

Mail
Aetna Better Health Premier Plan
Part D Appeals
Pharmacy Department
4500 E. Cotton Center Blvd.
Phoenix, AZ 85040
 
Fax
1-855-365-8108

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 HealthSM 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 HealthSM Premier Plan and your doctor or other prescriber may provide oral or written support for your request for an expedited appeal.
  2. Aetna Better HealthSM 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 functioning.

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 HealthSM Premier Plan will notify you and your doctor of the redetermination decision, following the timeframes below.

If Aetna Better HealthSM Premier Plan fails to make a redetermination decision and notify you within the timeframe, we must submit your redetermination case file to an Independent Review Entity (IRE) for review. We 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 HealthSM 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

 

 

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 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 to expedite your appeal if we believe that waiting for the standard timeframe will cause you serious harm. Aetna Better Health 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 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 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 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.