We update our covered drug list monthly. We may make changes based on findings from:
- The Food and Drug Administration (FDA)
- The Centers for Medicare & Medicaid Services (CMS)
- Clinical standards of care
We don’t often discontinue or reduce drug coverage during the plan year. We must notify you if we:
- Remove drugs from our list
- Add prior authorization, quantity limits or step therapy restrictions on a drug
- Move a drug to a higher cost-sharing tier
This must be at least 60 days before the change is effective. Or it may be when you request a refill of the drug. Then you’ll get a 60-day supply of the drug.
We’ll remove a drug from our formulary if either:
- The FDA views a drug on as unsafe
- The drug maker removes the drug from the market
We’ll send you a notice if you’re taking the drug.
Some covered drugs may have additional requirements or limits. These include:
- Prior authorization
You or your doctor may need approval for certain drugs before you fill your prescriptions. If you don’t get approval, we may not cover the drug.
- Quantity limits
For certain drugs, we limit the amount of the drug. We may limit coverage to 30 tablets for a 30-day supply. We may also limit fills to a one-month or three-month supply.
- Step therapy
In some cases, we require you to first try certain drugs to treat your condition before we cover another drug for that condition. For example, if drug A and drug B both treat your condition, we may not cover drug B unless you try drug A first. If drug A doesn't work for you, we'll then cover drug B.
Look in the formulary for more requirements or limits.
If you’re a member, you can request an exception if either:
- Your drug has a prior authorization, quantity limit, or step therapy requirement
- The drug isn't covered on our formulary
Request an exception online >
If you're requesting coverage of a medication under your prescription drug plan, or if you’re asking for advance approval to fill a prescription, you'll ask for a coverage decision or exception request (determination).
Request a drug coverage decision (determination)
Your doctor can request coverage on your behalf
Your doctor can call us at 1-800-414-2386 (TTY: 711), 7 days a week, 24 hours a day, to request drug coverage. Or your doctor can fax a completed, signed form with a statement of medical necessity to 1-800-408-2386.
You can use one of these methods:
You or your appointed representative can call us at 1-800-414-2386 (TTY: 711) to request drug coverage.
If you prefer, you can print and complete the appropriate forms below. Forms can be sent to us in one of three ways:
1. By fax: 1-800-408-2386
2. By mail:
Aetna Medicare
Coverage Determinations
P.O. Box 7773
London, KY 40742
3. You can also request coverage online.
Request coverage online >
Print our drug coverage determination request form
Print the hospice drug coverage request under Part D form
Print the Medicare program drug coverage determination request form
When you'll hear back
We’ll get back to you within 72 hours (24 hours if you request a faster decision). If your request is denied, you can file an appeal.
Requesting a drug appeal
If we deny your prescription drug request, you can appeal our decision. You can submit the online form, call us or download the coverage redetermination form. You can use either our form or the one from the Medicare program. Then fax or mail your request to us.
Appeal a denial online >
Download our appeals form
You'll leave Aetna Medicare and go to the CMS website if you select the link below.
Download the Medicare program appeals form
Fax: 1-800-408-2386
Mail:
Aetna Medicare Grievance & Appeals
PO Box 14579
Lexington, KY 40512
If you need an expedited (fast) decision, you can call or fax us.
- Expedited Phone Line: 1-877-235-3755 (TTY: 711), 7 days a week, 8 a.m. to 8 p.m.
- Expedited Fax Number: 1-860-907-3984
When you'll hear back
We’ll get back to you within 7 days (72 hours if you request a faster decision).
You may be on drugs that aren't on our list. They may have 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 your drug in certain cases during your first 90 days.
Request a transition supply
For any of your drugs not on our list or covered with additional requirements or limits, we'll cover up to a 30-day supply. This should allow you to work with your doctor to either transition to a new drug or request an exception to continue your current drug.
You must fill your prescription at a plan network pharmacy.
After your 30-day transition supply, we won't pay for these drugs unless you get approval for a drug exception. That is even if you're a plan member less than 90 days.
If you're a long-term care facility resident
You can refill your prescription until we've given you a transition supply (91-98-day supply). This may depend on drug maker packaging or if you have a prescription written for fewer days.
- We’ll cover more than one refill of these drugs for the first 90 days you’re a plan member.
- If you need a drug that’s not on our list or if your ability to get your medicine is limited, but you’re past the first 90 days of member, we’ll cover up to a 31-day emergency supply of that drug.
- If you’re discharged or move to a new long-term care facility, your doctor or pharmacy can request a one-time prescription override. This will give you up to a 30-day supply for that drug.
Learn more about our transition process
Click on the plus sign (+) for more information.
