You have rights if you have a problem or complaint about the pharmacy and 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 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week.
See Non-Part-D Opens In New Window for information on these processes for Medicare Part C benefits.
To speak with the Office of the Medicare Ombudsman (OMO) for help with a complaint, grievance or information request, visit the website of the Ombudsman on Medicare.gov.
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 the Evidence of Coverage - English Opens In New Window / Spanish Opens In New Window for detailed information and timelines for filing a grievance.
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 Better Health Premier Plan MMAI 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.
Aetna Better Health Premier Plan MMAI Formulary Opens In New Window
This information is also explained in the Aetna Better Health Premier Plan MMAI Evidence of Coverage - English Opens In New Window / Spanish Opens In New Window.
If you ask for a request to be reimbursed for a drug you paid for, Aetna Better Health Premier Plan MMAI will notify you or your authorized representative of its decision within 14 calendar days from the reciept of the request. If we determine in your favor, Aetna Better Health Premier Plan MMAI will make payment to you within 14 calendar days after we receive your request.
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 the Evidence of Coverage for more information about Part D prescription drug coverage decisions and appeals in the Aetna Better Health Premier Plan MMAI Evidence of Coverage - English Opens In New Window / Spanish Opens In New Window. To learn how many appeals and complaints Aetna Better Health Premier Plan MMAI has processed, please contact us at 1‑866‑600-2139 (TTY: 711), 24 hours a day, 7 days a week.
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