District Council 37 Health Security Plan Retirees
Get more out of your DC37/Aetna Medicare Rx (PDP)
District Council 37 Health & Security Plan/Aetna Medicare Rx (PDP)
This site is a resource to help you get the most out of your Medicare prescription drug plan benefits. Through this site, you can access information specific to the prescription drug plan made available to you through your union, including plan documents, contact numbers and website links.
Our service area includes all 50 states and the District of Columbia.
Benefits of Aetna Medicare Rx (PDP) for 2017(collapsed)
Your union has chosen to provide you with prescription drug coverage through Aetna Medicare Rx (PDP). Here are some of the advantages you can enjoy in 2017:
Access to approximately 65,000 retail network pharmacies
Lower out-of-pocket cost for Tier 1 preferred generic drugs if using a preferred network pharmacy or Aetna Rx Home Delivery (mail order pharmacy)
Generic (Tier 1 & Tier 2) coverage through the “donut hole”
Also known as the coverage gap
You pay for your brand-name prescription drugs (40% after manufacturer discount)
The coverage gap starts after you reach your initial coverage limit and lasts until you pay the true out of pocket amount
Access to Aetna Rx Home Delivery, to fill your prescriptions and save one month’s copay
Details of the 2017 Aetna Medicare Rx Plan (PDP)(collapsed)
Some covered drugs may have additional requirements or limits. These include:
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.
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.
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
How to ask for prescription drug coverage or request an appeal(collapsed)
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:
P.O. Box 7773
London, KY 40742
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.
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.
Your secure member website
If there's one tool to start using right way, it's Aetna Navigator. That's because this website puts all your plan information, health resources and online tools in one place. You can:
Manage your prescription cost.
See details about your plan and review your claims
Have real-time access to your Explanation of Benefits (EOB)
Or call Social Security at 1-800-772-1213 or TTY: 1-800-325-0778, Monday through Friday, 7 a.m. to 7 p.m.
Aetna members can receive help applying for Extra Help. To get help with your application, call "My Advocate" at 1-866-706-6757 (TTY: 711). They’re available Monday through Friday, 9 a.m. to 6 p.m. ET. "My Advocate" is a service offered by an independent company.
Most health care professionals and organizations that provide Medicare services are honest. Unfortunately, there may be some who are not. If you ever suspect fraud, please contact Member Services at the number on your ID card. Or call Medicare toll-free at 1-800-MEDICARE (1-800-633-4227), (TTY: 1-877-486-2048), 24 hours a day, 7 days a week.
For questions about Medicare eligibility and Social Security retirement benefits: