Part D complaints, coverage, decisions & appeals

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When to make a complaint

You may make a complaint if you have a problem with Aetna Better Health of Ohio, 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 behave
• Customer service
• Access to network pharmacies
• Being able to reach someone by telephone or get the information you need and complaints

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.

How to make a complaint

Whether you call or write, you should contact Member Services right away. You must make your complaint within 60 days after you have the problem you want to report.

• Start by calling Member Services. We’ll let you know what you need to do. 
  1-855-364-0974 (TTY: 711), 24 hours a day, seven days a week. The call is free.
• 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 Ohio
  PO Box 818070
  Cleveland, OH 44181
  Fax: 1-855-883-9555

For more information on the total number of grievances, appeals and exceptions with the health plan, please call Member Services at 1-855-364-0974 (TTY:711), 24 hours a day, seven days a week. The call is free.

Formal complaint procedure

If you write us, it means that 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.

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Requesting a fast complaint

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.

Quality of care complaints

If you have a complaint about your quality of care, you may make a complaint with the plan by calling Member Services at 1-855-364-0974 (TTY:711). We’re here 24 hours a day, seven days a week. We will research the complaint and send a response to you.

You also may file a grievance with Ohio's Quality Improvement Organization, Livanta:

Livanta

Attention: Beneficiary Complaints

10820 Guilford Rd., Suite 202

Annapolis Junction, MD 20701

Toll-free Phone: 1-888-524-9900

Toll-free TTY: 1-888-985-8775

Prescription drug transition policy

When you join Aetna Better Health of Ohio 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

All participants (new and renewing) in a Plan will be equally treated as new participants under the Transition Fill policy at the beginning of the new plan year.

If you are a new participant and are taking a drug that is not on the Aetna Better Health of Ohio 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 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 than30-day supply, you can get it refilled until you reach the up to a 30-day supply.

Renewing participants, who are taking a drug that was removed from the formulary or the drug now has anew 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.

New and existing participants of Aetna Better Health of Ohio may ask for a Coverage Determination and Exception Request by calling Member Services at 1-855-364-0974 (TTY/TDD: 711), 24 hours a day, 7 days a week.

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 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 PDF Opens In New Window to access a copy of the Coverage Determination and Exception Request form.

Please click here Opens In New Window to access a copy of our plan formulary for a complete listing of covered drugs. 

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 1-855-364-0974 (TTY: 711), 24 hours a day, seven days a week. The call is free.

Request an exception to the Formulary and Coverage Decisions

As a member of the Aetna Better Health of Ohio health 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 Health of Ohio 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.

2021 Prescription Drug Search Tool

2022 Prescription Drug Search Tool

This information is also explained in chapter 9, section 7 of the Aetna Better Health of Ohio Member Handbook (English Opens In New Window| Spanish Opens In New Window)

How to request a coverage decision

CVS Caremark is a Pharmacy Benefit Manager (PBM) that Aetna Better Health of Ohio has contracted to administer the Aetna Better Health of Ohio 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 of Ohio 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 Aetna Better Health of Ohio member services at the numbers 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 also can submit a coverage decision or exception request to Aetna Better Health of Ohio. 

Coverage decision form
You can ask Member Services to mail you a coverage decision form. You can download and print it to send by mail or fax. Or you can submit it online.

• Coverage Decision Form - submit online
• Coverage Decision Form - download and print PDF Opens In New Window

Call
Aetna Better Health of Ohio Member Services
1-855-364-0974 (TTY: 711), 24 hours a day, seven days a week. The call is free.

Fax
Part D Coverage Determinations
Pharmacy Department  
1-855-365-8108

Write
Aetna Better Health of Ohio
Part D Coverage Determination
Pharmacy Department
PO Box 30017
Pittsburgh, PA 15222-0330

How you are notified of a decision

If the decision is “yes” to cover part or all of what was requested, you will be notified and the drug or payment will be provided.

If the decision is “no,” you will be notified and receive a written notice explaining why it was denied and how you can appeal this decision. An unfavorable decision could be because the drug is not on the formulary, determined not to be medically necessary, or you have not tried a similar drug listed on the formulary. It could also be based on whether or not you have satisfied the prior authorization requirement. In most situations, this process cannot be applied to any excluded medications under state or federal law.

Coverage decision timeline

You have the right to a timely coverage decision (see table). If Aetna Better Health of Ohio 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).

DESCRIPTION	STANDARD COVERAGE DECISION	EXPEDITED COVERAGE DECISION
Coverage decisions	Aetna Better Health will notify you of a decision as fast as your health condition requires, but not later than 72 hours from the receipt of the request.	Aetna Better Health of Ohio 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 of Ohio 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 days.	Upon receipt of your doctor’s supporting statement for a formulary exception request, Aetna Better Health of Ohio will notify you as fast as your health condition requires but not later than 24 hours from the receipt of the request.

 

Coverage Decisions for Part D Drug Reimbursement:

Request for Payment: If you ask to be reimbursed for a drug you paid for, Aetna Better Health of Ohio 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.

 

 

Appeals

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

Please see chapter 9, section 7 for more information about Part D prescription drug coverage decisions and appeals in the Aetna Better Health of Ohio Member Handbook (English Opens In New Window | Spanish Opens In New Window).

To learn how many appeals and complaints Aetna Better Health of Ohio has processed, please contact us at 1-855-364-0974 (TTY: 711), 24 hours a day, seven days a week. The call is free.

How the appeals process works

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

How to submit an appeal request

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

How to submit an appeal or redetermination request
You can submit a redetermination request by phone, fax or mail. Or you can complete a coverage redetermination form online.

Coverage redetermination form
You can ask member services to mail you a coverage determination form. You can download and print it to send by mail or fax. Or, you can submit it online.

• Coverage Redetermination Form - submit online
• Coverage Redetermination Form - download and print PDF Opens In New Window

 
Phone
1-855-364-0974 (TTY: 711), 24 hours a day, seven days a week.

Mail

Aetna Better Health of Ohio

Part D Appeals

Pharmacy Department

PO Box 818001
Cleveland, OH 44181-8001

Fax: 1-855-365-8108

Requesting a fast appeal

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 Health of Ohio 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 Health of Ohio and your doctor or other prescriber may provide oral or written support for your request for an expedited appeal.
2. Aetna Better Health of Ohio 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.

What happens after you submit an appeal

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 Health of Ohio will notify you and your doctor of the redetermination decision, following the timeframes below.

If Aetna Better Health of Ohio fails to make a redetermination decision and notify you within the timeframe, Aetna Better Health of Ohio must submit your redetermination case file to Independent Review Entity (IRE) for review. Aetna Better Health of Ohio 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 Health of Ohio notifies you of an unfavorable decision, and you disagree, you may submit a reconsideration request (2^nd Level Appeal) to the Independent Review Entity (IRE). Instructions will be in the written notice.

Appeal levels and timelines

 

Level	DESCRIPTION	STANDARD APPEAL	EXPEDITED APPEAL
1	Redetermination by Aetna Better Health of Ohio	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 of Ohio 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 of Ohio to expedite your appeal if we believe that waiting for the standard timeframe will cause you serious harm.  Aetna Better Health of Ohio 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 of Ohio 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 of Ohio 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 of Ohio 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