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Grievance Procedures

The Prescription Drug Plan Grievance Process

Our grievance process is designed to address enrollee coverage issues, complaints and problems. If you have a coverage issue or other problem, please call Member Services at the toll-free number on your ID card. If Customer Services is unable to resolve your issue, complaint or problem to your satisfaction, you can request that your concern be forwarded to the regional grievance unit or you may write to the Grievance and Appeals address listed in the Evidence of Coverage you received.

Grievances can be filed orally or in writing and must be filed within 60 days of the event or incident. A quality of care grievance can be filed with Aetna or the Quality Improvement Organization (QIO). Grievances will be resolved as expeditiously as the case requires based on the enrollee's health status, but no later than 30 days from the date of receipt. Aetna or the enrollee can take up to a 14 day extension. If Aetna initiates an extension, the enrollee must be notified in writing and the letter must provide the reason for the delay.

Aetna will track all oral and written grievances received, including the date received, type of grievance and final disposition of the grievance, and the date the enrollee was notified of the final outcome or resolution.

If you would like to file an oral grievance, you may do so by contacting the following toll free Member Services numbers:

If you're enrolled in an Aetna Medicare stand-alone prescription drug plan, please call 1-877-238-6211. If you're enrolled in an Aetna Medicare Advantage plan that includes prescription drug coverage, please call 1-800-282-5366.

If you would like to file a grievance, you can mail us your written compliant or you may print and complete a copy of this form . Written complaints should be mailed to the address indicated below or you may fax them to the following toll-free fax number:

Address:	Aetna
	Medicare Pharmacy Grievance and Appeal Unit
	P.O. Box 14579
	Lexington, KY 40512
Telephone:	Expedited Appeals:	1-877-235-3755
	Grievances MAPD:	1-800-282-5366
	Grievances PDP:	1-877-238-6211
Fax Number:	All States:	1-866-604-7092

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Prescription Drug Coverage Determination Process

The following information provides a detailed description of the Coverage Determination and Exceptions process. If you would like to initiate a coverage determination or exception request, please print this form  and have your physician complete the necessary information and fax it to Aetna or they may also contact Aetna directly at the toll free number indicated on the form.

As a member of an Aetna Medicare Rx^SM Plan, an enrollee has the right to request a coverage determination concerning his/her rights with regard to the prescription drug coverage he/she is entitled to receive under their plan, including:

• Basic prescription drug coverage and supplemental benefits

• The amount including cost sharing, if any that an enrollee is required to pay for a drug

An adverse coverage determination constitutes any unfavorable decision made by or on behalf of Aetna regarding coverage or payment for prescription drug benefits an enrollee believes he or she is entitled to receive.

The following actions are considered coverage determinations:

• A decision not to provide or pay for a prescription drug (which includes a decision not to pay because the drug is not on the plan's formulary, determined to be not medically necessary, the drug is furnished by an out of network pharmacy or Aetna determines the drug is otherwise excluded under section 1862 (a) that the enrollee believes should be covered by the plan.)

• The failure to provide a coverage determination in a timely manner when a delay would adversely affect the health of the enrollee.

• A decision concerning an exceptions request for a plan's tiered cost sharing structure.

• A decision concerning an exceptions request involving a non formulary drug.

• A decision on the amount of cost sharing for a drug.

Aetna has both a standard and expedited procedure in place for making coverage determinations. The following is an explanation of each process.

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Assistance with Prescription Drug Coverage Determinations

You, your appointed representative or your prescribing physician can submit a request for a coverage determination or exception request either orally or in writing by contacting Aetna at:

Address:	Aetna Pharmacy Management Precertification Unit
	300 Highway 169 South Suite 500 Minneapolis, MN 55426
Telephone:	Pharmacy Precert:	1-800-414-2386
Fax Number:	Pharmacy Precert:	1-800-408-2386

Appointment of Representation

If you need assistance understanding or following the coverage determination, exceptions, appeals or grievance process, you can get assistance from a friend, lawyer or someone else. There are groups such as legal aid services that can help you find a lawyer or give you free legal services, if you qualify.

• The individual can be a relative, provider, friend, or someone else. (Note: A request made or supported by the enrollee's prescribing physician will be expedited if the physician indicates that applying the standard timeframe for making a determination may seriously jeopardize the life or health of the enrollee or the enrollee's ability to regain maximum function.)

If you would like to appoint a representative to assist you with the coverage determination, exceptions, appeals or grievance process, please print, complete and sign the following CMS Appointment of Representative form (CMS-1696) and include it with your written request.

CMS Appointment of Representative form (CMS-1696) 

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Standard Prescription Drug Coverage Determination Process

Upon receipt of a standard coverage determinations request, Aetna will review the request and make the determination.

1. Aetna will conduct the reconsideration and notify you in writing of the decision, using the following time frames:

   • Request for prescription drug benefits: When a party makes a request for drug benefits, Aetna will notify you or your authorized representative, and your prescribing physician as appropriate of its determination as expeditiously as your health condition requires, but no later than 72 hours from the receipt of the request or for an exceptions request, the physician's supporting statement.

   • Request for Payment: When a party makes a request for payment, Aetna will notify you or your authorized representative of its determination, no later than 72 hours from receipt of the request.

2. If Aetna decides fully in your favor on a request for a coverage determination you and your prescribing physician will receive written approval notification.

3. For denials related to drug coverage in whole or in part, Aetna will send a written notice of the determination to you and the prescribing physician involved. The denial notice will state the specific reason for the denial and contain all of the applicable Medicare appeals language. For denials related to payment, Aetna will also send a written notice containing all of the applicable Medicare appeal language.

4. If Aetna fails to make a coverage determination within the 72 hour timeframe it constitutes an adverse coverage determination. Aetna will send the request to the Independent Review Entity (IRE) designated by CMS within 24 hours of the expiration of adjudication timeframe and the IRE will issue a determination.

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Expedited Prescription Drug Coverage Determinations Process

1. You may file a request for an expedited coverage determination for drug coverage if you believe that applying the standard coverage determination process could jeopardize your health. If Aetna decides that the time frame for the standard process could seriously jeopardize your life, health or ability to regain maximum function, the review of your request will be expedited.

2. You, your appointed representative or your prescribing physician can request an expedited coverage determination. An expedited request can be submitted orally or in writing to Aetna and your prescribing physician may provide oral or written support for your request for an expedited coverage determination. A request made or supported by your prescribing physician will be expedited if your physician indicates that applying the standard timeframe for making a determination may seriously jeopardize your life or health or your ability to regain maximum function.

3. When Aetna determines that a request qualifies for expedited handling, we will make our determination as expeditiously as your health condition requires but no later than 24 hours after receiving the request, or for an exceptions request upon receipt of your physician's supporting statement. Both you and your prescribing physician will be notified of the decision, whether favorable or adverse. If Aetna first notifies you of an adverse decision orally, we will mail written confirmation to you within 3 calendar days of the oral notification. The written notice will also state the specific reason for the denial in understandable language and contain all of the applicable Medicare appeals language to ensure you are informed of your right to file a redetermination (appeal).

4. A request for payment of a covered prescription drug already furnished is not eligible for expedited processing.

5. To request an expedited coverage determination, you may call, fax or mail your written request to Aetna at the numbers indicated above. If you write, the 24-hour review time will not begin until your request is received.

6. If Aetna determines that your request is not time-sensitive, where your health is not seriously jeopardized, Aetna will notify you verbally and in writing and will automatically begin processing your request under the standard reconsideration process. If you disagree and believe the review should be expedited, you may file an expedited grievance with Aetna. The written notice will include instructions on how to file an expedited grievance.

7. If Aetna fails to make a coverage determination within the 24 hour timeframe it constitutes an adverse coverage determination. Aetna will send the request to the Independent Review Entity (IRE) designated by CMS within 24 hours of the expiration of the adjudication timeframe and the IRE will issue a determination.

8. You have the right to resubmit your request for an expedited coverage determination with your prescribing physician's support.

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The Prescription Drug Coverage Exceptions Process

Under the prescription drug coverage determination process you may initiate a exception request for the following situations:

• Request for exceptions involving a non-formulary Part D drug

• Requests for exceptions to a plans tiered cost sharing

1. A decision by Aetna concerning an exceptions request constitutes a coverage determination, therefore all of the applicable coverage determination requirements and timeframes apply.

2. Please refer your Evidence of Coverage, Section 8 for a complete description of the exceptions process. You may also view a copy of the Evidence of Coverage at the link titled “Applicable Forms”.

3. You, your appointed representative or your prescribing physician can submit an exception request either orally or in writing by contacting Aetna at:

   1-800-414-2386, or please fax your written request to 1-800-408-2386.

Address:	Aetna Pharmacy Management Precertification Unit
	300 Highway 169 South Suite 500 Minneapolis, MN 55426
Telephone:	Pharmacy Precert:	1-800-414-2386
Fax Number:	Pharmacy Precert:	1-800-408-2386

Aetna will track all standard and expedited coverage determination and exception requests received, including the date received, type of request and the final disposition of the request, and the date you are notified of the final disposition.

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Aetna has both a standard and expedited procedure in place for making redetermination decisions. The following is an explanation of each process.

The Prescription Drug Standard Appeals (redetermination) Process

The following information provides detailed description of the Appeals process. If you would like to initiate an appeal request, please print and complete this form  and fax or mail it to Aetna. If you feel your appeal needs to be handled expeditiously you may also contact Aetna directly at the toll free number indicated on below.

Address:	Aetna
	Medicare Pharmacy Grievance and Appeal Unit
	P.O. Box 14579
	Lexington, KY 40512
Telephone:	Expedited Appeals:	1-877-235-3755
	Grievances MAPD:	1-800-282-5366
	Grievances PDP:	1-877-238-6211
Fax Number:	All States:	1-866-604-7092

The appeals process, also referred to as a redetermination process, is used to review an adverse coverage determination made by the Aetna on the benefits that you believe you are entitled to receive. This includes a delay in providing or approving drug coverage (when the delay can affect your health), or on any amounts you must pay for drug coverage. Below is a description of the appeals process:

1. There are several levels of appeals that you can exercise (independent review entity, ALJ hearing and review by the Medicare Appeals Council).

2. You, your appointed representative or your prescribing physician can request an appeal (redetermination).

3. You must ask for an appeal by making a written request to Aetna and must file their request within 60 days of the adverse coverage determination.

   Upon receipt of a standard coverage determinations request, Aetna will review the request and make the determination within the following timeframes.

   • Standard appeal decisions (favorable or unfavorable) for covered drug benefits must be provided to you in writing (and effectuated if favorable) as expeditiously as your health condition requires but no later than 7 calendar days of receipt of the appeal request.

   • Standard appeal decisions (favorable or unfavorable) for requests for payment must be provided to you in writing (and effectuated if favorable) but no later than 7 calendar days of receipt of the appeal request.

   Failure to meet the timeframes noted constitutes an adverse determination and Aetna must forward your request to the Independent Review Entity (IRE) within 24 hours of the expiration of the adjudication timeframe for the IRE to issue the appeal (redetermination) decision. This applies to both standard and expedited appeal requests.

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The Prescription Drug Coverage Expedited Appeals (redetermination) Process

You may file a request for an expedited appeal for drug coverage if you believe you need and where you feel that applying the standard appeals process could jeopardize your health. If Aetna decides that the time frame 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 prescribing physician can request an expedited appeal. An expedited request can be submitted orally or in writing to Aetna and your prescribing physician may provide oral or written support for your request for an expedited appeal.

2. Aetna must provide an expedited appeal if it determines that applying the standard timeframe for making a determination may seriously jeopardize your life or health or your ability to regain maximum function.

3. A request made or supported by your prescribing physician will be expedited if the physician indicates that applying the standard timeframe for making a determination may seriously jeopardize your life or health or your ability to regain maximum function.

4. To request an expedited appeal, you may call 1-877-235-3755. Or you may fax or mail your written request to Aetna. If you write, the 24-hour review timeframe will not begin until your request is received. Written requests can be faxed to 1-866-604-7092 or mailed to the address in your Evidence of Coverage.

5. A request for payment of drugs that you have already received does not qualify for expedited appeals processing.

6. When an appeal request meets criteria for expedited processing Aetna must provide you and your prescribing physician notice of its decision as expeditiously as your health condition requires, but no later than 72 hours after receiving the request.

7. If additional medical information is required to process the request, Aetna must request it within 24 hours of receiving the expedited appeal request. Even if additional information is required, Aetna must still issue notice of the decision within the 72 hour timeframe.

8. If Aetna determines that your request is not time-sensitive, where your health is not seriously jeopardized, Aetna will notify you verbally and in writing and will automatically begin processing your request under the standard appeals process. If you disagree and believe the review should be expedited, you may file an expedited grievance with Aetna. The written notice will include instructions on how to file an expedited grievance.

9. You have the right to resubmit your request for an expedited appeal with your prescribing physicians support.

Aetna will track all standard and expedited appeals received, including the date received, type of appeal and the final disposition of the appeal, and the date you were notified of the final outcome or resolution.

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Applicable Forms Link

The following forms have been developed to assist members and physicians when requesting a prescription drug coverage determination, exception, appeal or grievance request.

Prescription Drug Coverage Determinations and Exception Requests

If you're requesting one of the following for your prescription drug coverage, you may use either of the following forms to make your request. To expedite the review process, print the form and have your physician complete the form and provide any applicable information to support the request and fax it to Aetna at 1-800-408-2386. You or your physician may also call Aetna's Pharmacy Precertification unit directly to ask questions or initiate an oral request by calling 1-800-414-2386.

• prior authorization or other utilization management review
• request for exception and approval for a non-formulary medication
• request for exceptions to a plans tiered cost sharing

Aetna APM Precert form  
CMS Exceptions form  

Prescription Drug Appeals and Grievance Requests

If you've received a denial letter for a prescription drug that you or your physician requested, you may use the following form to request an expedited or standard appeal. Please review the instructions included on the form and complete all of the applicable information to support your request. The form can be faxed or mailed to Aetna at the fax number or address indicated below. If you or your physician feels your appeal request should be expedited the request can be initiated orally by contacting Aetna at the expedited appeals phone number indicated below.

Our grievance process is designed to address enrollee coverage issues, complaints and problems. If you have a coverage issue or other problem, please call Member Services at the toll-free number on your ID card. If Member Services is unable to resolve your issue, complaint or problem to your satisfaction, you can request that your concern be forwarded to the regional grievance unit or you may complete the following form to file your written compliant. Please mail or fax the completed form to the Grievance and Appeals address listed below.

Aetna's Appeals & Grievance form  

Address:	Aetna
	Medicare Pharmacy Grievance and Appeal Unit
	P.O. Box 14579
	Lexington, KY 40512
Telephone:	Expedited Appeals:	1-877-235-3755
	Member Services PDP:	1-877-238-6211
	Member Services MAPD:	1-800-282-5366
Fax Number:	All States:	1-866-604-7092

If you or your physician has general questions about the appeals or grievance process you may contact the applicable Member Services number indicated above. If you have questions regarding the status of your appeal or grievance, you may contact the applicable Member Services number indicated above and a Customer Service Representative will determine who is handling your case and obtain status for you.

Appointment of Representation

If you need assistance understanding or following the coverage determination, exceptions, appeals or grievance process, you can get assistance from a friend, lawyer or someone else. There are groups such as legal aid services that can help you find a lawyer or give you free legal services, if you qualify.

• The individual can be a relative, provider, friend, or someone else. (Note: A request made or supported by the enrollee's prescribing physician will be expedited if the physician indicates that applying the standard timeframe for making a determination may seriously jeopardize the life or health of the enrollee or the enrollee's ability to regain maximum function.)

If you would like to appoint a representative to assist you with the coverage determination, exceptions, appeals or grievance process, please print, complete and sign the following CMS Appointment of Representative form (CMS-1696) and include it with your written request.

CMS Appointment of Representative form (CMS-1696)  

For a complete description of Aetna's Prescription Drug Coverage Determination, Exception, Appeals and Grievance process, please refer to Sections 7 and 8 of the attached Evidence of Coverage. Please refer to the Summary of Benefits and Evidence of Coverage provided to you for a complete description of your specific benefit plan and coverage.

2008 Summaries of Benefits

Number of Appeals and Grievances

If you would like to learn how many appeals and grievances Aetna processed, please go to the government's Medicare website, www.medicare.gov.

• Select "Learn More About Plans In Your Area"
• Then select your "State" and "Continue"
• Then select your county in "Select a county" and "Continue"
• From the page "Plans in Your Area" under "Review List of Plans", select "Get Plan Performance Information" and find Aetna's plans

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Contact Us
Questions? Call us at 1-800-529-5586, (TTY/TDD 1-800-628-3323)
Monday - Friday, 8 a.m. - 6 p.m.
 Find general Medicare contact information.

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Updated 10/2007