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 covered by Aetna Better Health Premier Plan MMAI, including specialty drugs. This section also provides information about coverage limitations that may apply to some covered drugs.  You can also learn about our Medication Therapy Management Program and low-income subsidy.

Prescription drugs are often an important part of managing a health issue. 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.

If you need a drug that is not on the List of Covered Drugs (formulary), your prescriber must provide a statement that says you have tried the formulary medications and they did not work for you, or a medical reason why you cannot try the formulary medications.

Your Aetna Better Health Premier Plan MMAI formulary is below. 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. If you have any questions about a drug that is not listed, please call Member Services at 1‑866‑600-2139 (TTY: 711), 24 hours a day, seven days a week.

Find out if your medicine is covered
A formulary is a list of drugs covered by Aetna Better Health Premier Plan MMAI. It also is sometimes called a prescription drug list. Aetna Better Health Premier Plan MMAI consulted with team of health care providers to develop the formulary. It includes prescription therapies believed to be a necessary part of a quality treatment program.

Aetna Better Health Premier Plan MMAI generally covers the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Aetna Better Health Premier Plan MMAI network pharmacy, and other plan rules are followed.

View the 2024 Formulary Search Tool

View Formulary List

Formulary updates

Contact us for the most recent list of drugs at 1‑866‑600-2139 (TTY: 711), 24 hours a day, seven days a week.

You can register on the Caremark.com member portal to use the “Real-Time Benefit Tool”.  With this tool you can search for drugs on the “Drug List” to see an estimate of what you will pay and if there are alternative drugs on the “Drug List” that could treat the same condition.  Once registered, you can access the tool under the Plan & Benefits section and then clicking on the “Check Drug Cost & Coverage” option.

Can you ask for an exception to cover your drug?

Yes. You can ask Aetna Better Health Premier Plan MMAI 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 MMAI 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 1‑866‑600‑2139 (TTY: 711), 24 hours a day, seven days a week. A Member Services representative will work with you and your provider to help you ask for an exception.

Download the Prior Auth Form

 

View your 2024 Pharmacy Search Tool

Contact us for the most recent list of drugs at 1‑866‑600-2139 (TTY: 711), 24 hours a day, seven days a week.

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, for a chronic or long-term medical condition. The drugs that are not available through the plan’s mail-order service are marked as “NM – Not available at Mail-order” on the formulary list.

Our plan’s mail-order service allows you to order up to a 90-day supply.

Download the Prescription Drug Mail-order Form English|Spanish here.

To get order forms and information about filling your prescriptions please call Aetna Better Health Premier Plan Member Services at 1-866-600-2139 (TTY: 711), 24 hours a day, seven days a week to request a mail order form or you can register on line 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 the address printed on the form. If there is no address on the form, you can mail it to: 

CVS/Caremark
PO BOX 94467
PALATINE, IL 60094-4467

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.

Usually a mail-order pharmacy order will get to you in no more than 21 days. If a mail order is delayed by the mail order pharmacy 21 days or more, you will be contacted and told about the delay. If you have not received an order within 21 calendar days of when you sent the order, call CVS Caremark Customer Care at 1-844-843-6264 (hearing impaired only, TTY 1-800-231-4403) and they will begin processing a replacement order. The order will be quickly sent to you. Calls to this number are free.

Prescription Mail-order Form English|Spanish

Aetna Better Health Premier Plan MMAI requires you (or your physician) to get prior authorization for some drugs. This means that you need to get approval from Aetna Better Health Premier Plan MMAI before you fill your prescriptions. If you don’t, Aetna Better Health Plan MMAI may not cover the drug. Learn more about Prior Authorization Criteria.

Download the Prior Authorization Form 

Download the Hospice Exception Form for Medicare Part D plans.

Visit the 2024 Formulary Search Tool

Contact us for the most recent list of drugs at 1‑866‑600-2139 (TTY: 711), 24 hours a day, seven days a week.

Non-formulary Requests:

If you need a drug that is not on the List of Covered Drugs (formulary), your prescriber must provide a statement that says you have tried the formulary medications and they did not work for you, or a medical reason why you cannot try the formulary medications.

Sometimes Aetna Better Health® Premier Plan MMAI needs you first to try certain drugs to treat your medical condition before it covers another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Aetna Better Health Premier Plan MMAI may not cover Drug B unless you try Drug A first. If Drug A does not work, Aetna Better Health Premier Plan MMAI then covers Drug B. Learn more about Step Therapy Criteria.

Visit the 2024 Formulary Search Tool

Contact us for the most recent list of drugs at 1‑866‑600-2139 (TTY: 711), 24 hours a day, seven days a week.

Find out if your medicine is covered

A formulary is a list of drugs covered by Aetna Better Health® Premier Plan MMAI. It also is sometimes called a prescription drug list. Aetna Better Health Premier Plan MMAI consulted with team of health care providers to develop the formulary. It includes prescription therapies believed to be a necessary part of a quality treatment program.

Aetna Better Health Premier Plan MMAI generally covers the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Aetna Better Health Premier Plan MMAI network pharmacy, and other plan rules are followed. View the Formulary List

View the 2024 Formulary Search Tool

If there is a limit on the amount of drug covered and you need a higher quantity than what is covered your prescriber must provide a statement that says:

  • you have tried the formulary quantity limit and it didn’t work, or
  • a medical reason why you cannot use the formulary quantity limit or higher strength of the requested medication, or
  • the amount of medication allowed by our plan is not effective or likely to be ineffective for the treatment of your medical condition.

Contact us for the most recent list of drugs at 1‑866‑600-2139 (TTY: 711), 24 hours a day, seven days a week.

When you change health plans, you may find you now have different benefits. You also may have different drug coverage. We want to make your transition easy for you. 

If you join our plan and find out we don’t cover a prescription drug you’ve been taking, let us know. You may be on drugs that aren't on our drug list or covered with added requirements or limits. 

Talk with your doctor 

Your doctor can help you decide if you should switch to a covered drug or request a drug exception. It may help to share your formulary with your doctor. In the meantime, we may cover a temporary supply of your drug in certain cases during your first 90 days. You may be able to get at least a one-time fill of a 30-day (or less, as prescribed, up to a 30-day supply) supply of that drug at retail pharmacy.

This gives you a chance to work with your doctor to find a new treatment plan and avoid disruption. This process is called Prescription Drug Transition Policy/Transition of Coverage (TOC). Learn about how the prescription drug transition policy works.

After your 30-day transition supply, we won't pay for these drugs unless you get approval for a drug exception.

If you have questions or would like more information about our transition policy, please call Member Services toll-free at 1-866-600-2139 (TTY: 711), 24 hours a day, seven days a week.

Medication Therapy Management Program

The Aetna Better Health Premier Plan MMAI Medication Therapy Management (MTM) Program is all about you and your health. The MTM Program helps you get the most out of your medications by:

  • Preventing or reducing drug-related risks
  • Supporting good lifestyle habits
  • Providing information for safe medication disposal options

Who qualifies for the MTM Program?
You will be enrolled in the Aetna Better Health Premier Plan MMAI MTM Program if you meet one of the following:

  1. Have coverage limitation(s) in place for medication(s) with a high risk for dependence and/or abuse, or
  2. Meet the following criteria:
    • You have three or more of these conditions:
      • Asthma
      • Chronic heart failure (CHF)
      • Chronic obstructive pulmonary disease (COPD)
      • Diabetes
      • Dyslipidemia
      • Hypertension
      • Chronic alcohol & drug dependence
      • HIV/AIDS
    • You take eight or more routine medications covered by your plan
    • You are likely to spend more than $5,330 in Part D prescription drug costs in 2024

Your participation in the MTM Program is voluntary and does not affect your coverage. This is not a plan benefit and is open only to those who qualify. There is no extra cost to you for the MTM Program.

How will I know if I qualify for the MTM Program?

If you qualify, we will mail you a letter. You may also receive a call to set up your one-on-one medication review.  

What services are included in the MTM Program?

In the MTM Program, you will receive the following services from a health care provider:

  • Comprehensive medication review
  • Targeted medication review

What is a comprehensive medication review?

The comprehensive medication review is completed with a health care provider in person or over the phone. This review is a discussion that includes all your medications:

  • Prescriptions
  • Over-the-counter (OTC)
  • Herbal therapies
  • Dietary supplements

This review usually takes 20 minutes or less to complete. During the review, you may ask any questions about your medications or health conditions. The health care provider may offer ways to help you manage your health and get the most out of your medications. If more information is needed, the health care provider may contact your prescriber.

After your review, you will receive a summary of what was discussed. The summary will include the following:

  • Recommended To-Do List. Your to-do list may include suggestions for you

and your prescriber to discuss during your next visit.

  • Medication List. This is a list of all the medications discussed

during your review. You can keep this list and share it with your prescribers

and/or caregivers.

  • Here is a blank copy of the Medication List for tracking your medications For Spanish medication list click here.

Who will contact me about completing the review?

You may receive a call from a pharmacy where you recently filled one or more of your prescriptions. You can choose to complete the review in person or over the phone.

A health care provider may also call you to complete your review over the phone. When they call, you can schedule your review at a time that is best for you.

  • Trusted MTM Program partners: You may receive a call from the CVS Caremark Pharmacist Review Team or the Outcomes Patient Engagement Team to complete this service.

Why is this review important?

Different prescribers may write prescriptions for you without knowing all the medications you take. For that reason, the MTM Program health care provider will:

  • Review all your medications
  • Discuss how your medications may affect each other
  • Identify any side effects from your medications
  • Help you reduce your prescription drug costs

How do I benefit from talking with a health care provider?

By completing the medication review with a health care provider, you will:

  • Understand how to safely take your medications
  • Get answers to any questions you may have about your medications or health conditions
  • Review ways to help you save money on your drug costs
  • Receive a Recommended To-Do List and Medication List for your records and to share with your prescribers and/or caregivers

What is a targeted medication review?

The targeted medication review is completed by a health care provider who reviews your medications at least once every three months. With this review, we mail, fax, or call your prescriber with suggestions about prescription drugs that may be safer or work better for you. As always, your prescriber will decide whether to consider our suggestions. Your prescription drugs will not change unless you and your prescriber decide to change them. We may also contact you by mail or phone with suggestions about your medications.

How can I get more information about the MTM Program?

Please contact us if you would like more information about the Aetna Better Health Premier Plan MMAI MTM Program or if you do not want to participate. Our number is 1-866-600-2139, 24 hours a day, 7 days a week. (TTY users, call 711).

How do I safely dispose of medications I don’t need?

The Aetna Better Health Premier Plan MMAI MTM Program is dedicated to providing you with information about safe medication disposal. Medications that are safe for you may not be safe for someone else. Unneeded medications should be disposed of as soon as possible. You can discard your unneeded medications through a local safe disposal program or at home for some medications. 

  • Locating a community safe drug disposal site

A drug take back site is the best way to safely dispose of medications. To find drug take back sites near you, visit the website below and enter your location:

https://apps2.deadiversion.usdoj.gov/pubdispsearch/spring/main?execution=e2s1

Some pharmacies and police stations offer on-site drop-off boxes, mail-back programs, and other ways for safe disposal. Call your pharmacy or local police department (non-emergency number) for disposal options near you.

  • Mailing medications to accepting drug disposal sites

Medications may be mailed to authorized sites using approved packages. Information on mail-back sites can be found at www.deatakeback.com

  • Safe at-home medication disposal

You can safely dispose of many medications through the trash or by flushing them down the toilet. Visit the following website first to learn what medications are safe to dispose of at home:

https://www.hhs.gov/opioids/prevention/safely-dispose-drugs/index.html

Steps for medication disposal in the trash:

    • Remove medication labels to protect your personal information
    • Mix medications with undesirable substances, such as dirt or used coffee grounds
    • Place mixture in a sealed container, such as an empty margarine tub

 

 

View CMS Best Available Evidence (BAE) information.

Disenrollment
Disenrollment means that you are no longer a member of Aetna Better Health® Premier Plan MMAI. 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 MMAI can ask HFS to disenroll you from our health plan. This is called “disenrollment for cause.” Aetna Better Health Premier Plan MMAI 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 MMAI 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 MMAI 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 MMAI 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 MMAI if you move out of the service area. Aetna Better Health Premier Plan MMAI serves members in the following counties only:

  • Cook
  • DuPage
  • Kane
  • Will

*Effective 7/1/2021, our service area will expand to include these counties in Illinois:

Region 1 Northwestern counties – Boone, Bureau, Carroll, DeKalb, Fulton, Henderson, Henry, Jo Daviess, Knox, LaSalle, Lee, Marshall, Mercer, Ogle, Peoria, Putnam, Rock Island, Stark, Stephenson, Tazewell, Warren, Whiteside, Winnebago, Woodford

Region 2 Central counties – Adams, Brown, Calhoun, Cass, Champaign, Christian, Clark, Coles, Cumberland, DeWitt, Douglas, Edgar, Ford, Greene, Hancock, Iroquois, Jersey, Livingston, Logan, Macon, Macoupin, Mason, McDonough, McLean, Menard, Montgomery, Morgan, Moultrie, Piatt, Pike, Sangamon, Schuyler, Scott, Shelby, Vermilion

Region 3 Southern counties – Alexander, Bond, Clay, Clinton, Crawford, Edwards, Effingham, Fayette, Franklin, Gallatin, Hamilton, Hardin, Jackson, Jasper, Jefferson, Johnson, Lawrence, Madison, Marion, Massac, Monroe, Perry, Pope, Pulaski, Randolph, Richland, Saline, St. Clair, Union, Wabash, Washington, Wayne, White, Williamson

Region 4 Cook County

Region 5 Collar counties – DuPage, Grundy, Kane, Kankakee, Kendall, Lake, McHenry, 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 MMAI. 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 MMAI 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.

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 MMAI Member Services at 1-866-600-2139 (TTY: 711), 24 hours a day, seven days a week.

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.

Additional Resources

Please contact Member Services at 1-866-600-2139 (TTY: 711) for additional information.

Other resources include:

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 MMAI Member Services at 1-866-600-2139 (TTY: 711), 24 hours a day, seven days a week.