Part D Complaints, Coverage Decisions & Appeals
You have rights if you have a problem or complaint about the pharmacy or medical care you receive. Learn more about the complaints, coverage decisions and appeals process for medical care below. You have the right to get information about appeals, complaints, and exceptions that other members have filed against our plan. Call Member Services at 1-855-463-0933 (TTY: 711), 8 AM to 8 PM, seven days a week.
See Non-Part D complaints, coverage decisions and appeals for information on these processes for Medicare Part C benefits.
Speak with the Office of the Medicare Ombudsman (OMO) for help with a complaint, grievance or information request.
For information on the total number of grievances, appeals and exceptions with the health plan, please call Member Services at 1-855-463-0933 (TTY: 711), 8 AM to 8 PM, seven 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 your Evidence of Coverage.
When to file a complaint
You may make a complaint if you have a problem with Aetna 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 file a complaint
Whether you call or write, you should contact Member Services right away. You can file a complaint at any time.
- Start by calling Member Services at 1-855-463-0933 (TTY: 711), 8 AM to 8 PM, seven 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:AetnaPO Box 818070
Cleveland, OH 44181
For more information on the total number of grievances, appeals and exceptions with the health plan, please call Member Services at 1-855-463-0933 (TTY: 711), 8 AM to 8 PM, seven days a week.
Filing a formal complaint
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.
Complaints to Medicare
You are now able to submit feedback about your Medicare health plan or prescription drug plan directly to Medicare.
Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. If you have any other feedback or concerns, or if you feel the plan is not addressing your problem, please call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users can call 1-877-486-2048. The call is free.
See information about complaints and grievances in your Evidence of Coverage.
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 complaint
If you have a complaint about your quality of care, you may make a complaint with the plan by calling Member Services at 1-855-463-0933 (TTY: 711), 8 AM to 8 PM, seven 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 is Virginia’s Quality Improvement Organization. You may contact Livanta at 1-888-396-4646 or by writing:
10820 Guilford Road, Suite 202
Annapolis Junction, MD 20701
Prescription drug transition policy
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 able to get at least a one-time supply of that drug. 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). 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.
Learn more about how the Prescription Drug Transition Policy works.
If you have questions or would like more information about our transition policy, please call Member Services toll-free at 1-855-463-0933 (TTY: 711), 8 AM to 8 PM, seven days a week.
Request an exception to the Formulary and Coverage Decisions
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 request we pay for a prescription drug you already bought.
If your pharmacist tells you your prescription drug claim was rejected, the pharmacist will give you a written notice explaining how to request a coverage determination or exception.
Aetna has a list of covered Part D prescription drugs called a formulary. Your network doctor will refer to the formulary and typically prescribe a drug from it to meet your medical needs. Not all prescription drugs are listed on our formulary. Some formulary prescription drugs may require prior authorization, step therapy or have quantity limits.
How to request a coverage decision
CVS Caremark is a Pharmacy Benefit Manager (PBM) that Aetna has contracted to administer the Aetna Medicare Advantage Dual Eligible Special Needs 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 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 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.
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.
Call: Member Services 1-855-463-0933 (TTY: 711), 8 AM to 8 PM, seven days a week
Fax: Part D Coverage Determinations, Pharmacy Department 1-877-270-0148
Part D Coverage Determination
4750 S. 44th Place Suite 150
Phoenix, AZ 85040-4015
How you are notified of a decision
If the decision is “yes” to cover part or all of what was requested, we will notify you and will provide the drug or payment.
If the decision is “no,” we will notify you. You will 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 met the prior authorization requirement. In most situations, this process cannot be applied to any medications excluded under state or federal law.
Coverage decision timeline
You have the right to a timely coverage decision (see table). If Aetna 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 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 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 will notify you as fast as your health condition requires but not later than 72 hours from the receipt of the request. Upon receipt of your doctor's supporting statement for a formulary exception request, Aetna 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 reimbursement: If you ask to be reimbursed for a drug you paid for, Aetna will notify you or your authorized representative of its decision within 14 calendar days from the receipt of the request. If we determine in your favor, Aetna will make payment to you within 14 calendar days after we receive your request.
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 your Evidence of Coverage for more information about Part D prescription drug coverage decisions and appeals.
To learn how many appeals and complaints Aetna has processed, please contact us at 1-855-463-0933 (TTY: 711), 8 AM to 8 PM, seven days a week.
How to submit an appeal request
If you are notified of a coverage decision denial by Aetna, 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 submit it online. The request needs to include a supporting statement from your doctor to provide the medical reasons for the drug requested.
Phone: 1-855-463-0933 (TTY: 711), 8 AM to 8 PM, seven days a week
Fax: Part D Appeals 1-877-270-0148
AetnaPart D AppealsPharmacy Department4750 S. 44th Place Suite 150
Phoenix, AZ 85040-4015
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 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.
- 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 and your doctor or other prescriber may provide oral or written support for your request for an expedited appeal.
- Aetna 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.
- 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 will notify you and your doctor of the redetermination decision, following the timeframes below.
If Aetna fails to make a redetermination decision and notify you within the timeframe, Aetna must submit your redetermination case file to Independent Review Entity (IRE) for review. Aetna 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 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.
Redetermination by Aetna
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 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 to expedite your appeal if we believe that waiting for the standard timeframe will cause you serious harm. Aetna 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 does not agree that your appeal requires a fast review, you will be notified that the standard timeframe will be applied.
Reconsideration by Independent Review Entity (IRE
If Aetna 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 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.
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.
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.
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.