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 that Aetna Better Health Premier Plan covers, including specialty drugs. This section also lets you know about coverage limitations that may apply to some drugs. You can also learn more about our Medication Therapy Management Program and low-income subsidy. 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.
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.
Prescription drugs are often an important part of your health care. 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. If you have any questions about a drug that is not listed, please call Member Services at 1-855-676-5772 (TTY: 711), 24 hours a day, 7 days a week. The call is free.
Formulary and search tool
A formulary is a list of drugs that Aetna Better Health Premier Plan covers. It’s sometimes called a List of Drugs. We consulted with a team of health care providers to develop the formulary. It includes prescription therapies we believe are a necessary part of a quality treatment program.
We generally cover the drugs in our formulary as long as:
- The drug is needed to treat an illness or injury
- Your prescription is filled at a pharmacy in our network
- You follow any other plan rules that apply
View the List of Covered Drugs
You can get this information for free in other languages. Call 1-855-676-5776, (TTY: 711), 24 hours a day, 7 days a week. The call is free. And you can contact us for the most recent list of drugs at 1-855-676-5776 (toll-free), 24 hours a day, 7 days a week. TTY MI Relay 711.
Contact us for the most recent list of drugs at 1-855-676-5776 (toll-free), 24 hours a day, 7 days a week. TTY MI Relay 711.
Prescription drug transition policy
When you join Aetna Better Health℠ Premier Plan and you learn that we do not cover a prescription drug you were taking before you joined our Plan, you may be able to get a temporary fill of up to a 30-day supply of that prescription drug (or less, as prescribed) at a retail pharmacy. This gives you the opportunity to work with your doctor to complete a successful transition to your new coverage year and avoid disruption in your treatment. This is called the Transition of Coverage (TOC) process. 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 coverage 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 If you are a new member and are taking a drug that is not on the Aetna Better Health℠ Premier Plan formulary, or is subject to a utilization management requirement or limitation (such as step therapy, prior authorization, or a quantity limit), you are entitled to receive up to a 30-day supply of the Part D drug within the first 90-days of your enrollment. This period of time is called your “transition period”. If your prescription is written for less than 30-day supply, you can get it refilled until you reach the up to a 30-day supply.
Existing members, who are taking a Part D drug that was removed from the formulary or the drug now has a new utilization requirement or limitation at the beginning of the new plan year, also get a “transition period”. You can get up to a 30-day supply of medication during the first 90-days of the new plan year. If your prescription is written for less than a 30-day supply, you can get it refilled until you reach the up to a 30-day supply.
In general, we will determine your right to a 30-day fill at the pharmacy when you go to fill your prescription. In some situations, we will need to get additional information from your doctor before we can determine if you are entitled to a transition to a 30-day fill.
If you live in a Long Term Care facility, and are entitled to a transition supply, we will allow you to refill your prescription until we have provided you with up to a 31-day supply (unless the prescription is written for less) during your transition period.
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 a 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.
Please click here to access a copy of the Coverage Determination and Exception Request form.
Please click here to access a copy of our plan formulary for a complete listing of covered drugs.
Please click here to review a sample of the transition of coverage letter.
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 1-855-676-5772 (TTY: 711), 24 hours a day, 7 days a week.
Aetna Better Health℠ Premier Plan is a health plan that contracts with both Medicare and Michigan Medicaid to provide benefits of both programs to enrollees.
Request an exception to the formulary and coverage decisions
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 1-855-676-5772 (TTY: 711), 24 hours a day, and 7 days a week. A Member Services representative will work with you and your provider to help you ask for an exception.
Medication Management Therapy Program
Medication Therapy Management Program
The Aetna Better Health of Michigan 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 of Michigan 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:
- Chronic obstructive pulmonary disease
- Chronic heart failure
- 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 1-855-676-5772, (TTY: 711) 24 hours a day, 7 days a week. The call is free.
Opioid requirements and Drug Management Program
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.
Contact your Medicare drug plan for additional information. You can find contact information in your member materials or on your membership card.
Other resources include:
- “Your Guide to Medicare Prescription Drug Coverage” at: www.Medicare.gov/publications
- “How Medicare Drug Plans use Pharmacies, Formularies, & Common Coverage Rules” at: https://www.medicare.gov/Pubs/pdf/11136-Pharmacies-Formularies-Coverage-Rules.pdf
- Call the State Health Insurance Assistance Program (SHIP). Visit www.shiptacenter.org or call 1-800-MEDICARE for the phone number of your SHIP.For resources and information about the National Opioid Crisis go to: www.hhs.gov/opioids or the Center for Disease Control (CDC) at: https://www.cdc.gov/drugoverdose/epidemic/index.html
For more information on what Medicare covers and drug coverage rules, visit Medicare.gov. You can also call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
Aetna Better Health of Michigan requires you (or your physician) to get prior authorization for some drugs. This means that you need to get approval from Aetna Better Health of Michigan before you fill your prescriptions. If you don’t, Aetna Better Health of Michigan may not cover the drug. View the Prior Authorization Criteria.
Download the Prior Authorization Form
Download the Hospice Part D exception form
Visit the 2020 Aetna Better Health of MI Prescription Drug Search or the 2021 Aetna Better Health of MI Prescription Drug Searchor contact us for the most recent list of drugs at 1-855-676-5772 (toll-free), 24 hours a day, 7 days a week. TTY Relay Michigan 711.
Aetna Better Health Premier Plan limits the amount of some drugs that we cover. For example, the plan covers 90 pills in 30 days for a prescription for Oxycodone HCL. This may be in addition to a standard 1-month or 3-month supply.
Download the List of Covered Drugs
Visit the online formulary tool or contact us for the most recent list of drugs at 1-855-676-5776 (toll-free), 24 hours a day, 7 days a week. TTY MI Relay 711.
Sometimes we need you to first try certain drugs to treat your medical condition before we cover another drug for that same condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A doesn’t work, we then cover Drug B. View the Step Therapy Criteria.
Visit the online formulary tool or contact us for the most recent list of drugs at 1‑855-676-5772 (TTY: 711) , 24 hours a day, 7 days a week.
Find a pharmacy
Mail order prescriptions
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. These are often for a chronic or long-term medical condition. The drugs that are not available through the plan’s mail-order service are marked as “non-maintenance” drugs in our Drug List.
Our plan’s mail-order service requires you to order a 90-day supply.
Download the Prescription Drug Mail Order form here. To get order forms and information about filling your prescriptions by mail, call Member Services at 1-855-676-5772 (TTY: 711). Representatives are on call 24 hours a day, 7 days a week. You can request a mail-order form or you can register online 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:
PO Box 2110
Pittsburgh, PA 15230-2110
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.
If a mail order is delayed 21 days or more, the pharmacy will contact you about the delay. If they don’t contact you, and you haven’t received your order in time, you can call CVS Caremark Customer Care toll-free at 1-800-552-8159 (TTY 1-800-231-4403). They will process a replacement order. You should receive this quickly.
Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacies
An Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy means a pharmacy operated by the Indian Health Service, an Indian tribe or tribal organization, or an urban Indian organization, all of which are defined in Section 4 of the Indian Health Care Improvement Act, 25 U.S.C. 1603.
To get information about filling your prescriptions at an IHS/ITU Pharmacy please call Aetna Better Health Premier Plan Member Services at 1-855-676-5772 (TTY: 711), 24 hours a day, 7 days a week.
Long Term Care Pharmacies (LTC)
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 1-855-676-5772 (TTY: 711), 24 hours a day, 7 days a week.
Home Infusion Pharmacies (HI)
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 1-855-676-5772 (TTY: 711), 24 hours a day, 7 days a week.