CurrentAetnaPolicy N/A

Request for Redetermination of Medicare Prescription Drug Denial

Form and instructions for Medicare prescription drug enrollees (Silverscript/Aetna) to request a redetermination (appeal) after a denial of coverage or payment; applies to plan members, prescribers, and authorized representatives.

Policy Summary

PayerAetna

PolicyRequest for Redetermination of Medicare Prescription Drug Denial

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionEnrollees or prescribers may request a redetermination within 65 days of the Notice of Denial and may request expedited review (72-hour decision) if waiting would seriously harm health.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

65 daystimeframe to file

72 hoursexpedited decision time

7 daysstandard wait period

1-866-235-5660expedited phone

1-855-633-7673fax

Documentation and Submission Requirements

Documentation and submission criteria for redetermination

Information and documentation required to support a redetermination request:

Include a copy of the Notice of Denial of Medicare Prescription Drug Coverage (attach to the redetermination request).

Provide a clear explanation of why you believe the drug should be covered and attach any supporting information (e.g., prescriber statement, medical records).

Prescriber statement: the prescriber must explain why the enrollee cannot meet the plan's coverage rules and/or why the drugs required by the plan are not medically appropriate for the enrollee. Attach this statement when relevant (required for clinical justification).

If the drug was already purchased, attach a copy of the receipt and provide the date purchased and amount paid; include pharmacy name and phone number as available.

Policy Summary

PayerAetna

PolicyRequest for Redetermination of Medicare Prescription Drug Denial

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionEnrollees or prescribers may request a redetermination within 65 days of the Notice of Denial and may request expedited review (72-hour decision) if waiting would seriously harm health.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

How to Request a Redetermination / Expedited Review

Prior Authorization

Request redetermination within 65 days; use expedited review when delay would cause serious harm

Enrollees or prescribers must request a redetermination within 65 days of the Notice of Denial; prescribers may file on the enrollee’s behalf and a representative may be named by calling 1-866-235-5660. Expedited (fast) appeals are available — check the expedited box and attach a prescriber’s supporting statement to request a decision within 72 hours when waiting 7 days could seriously harm life, health, or ability to regain maximum function; if the prescriber indicates waiting 7 days could seriously harm the member, the appeal will automatically be handled within 72 hours. Expedited requests cannot be used for reimbursement-only claims.

File standard redetermination within 65 days of the Notice of Denial (or file online at www.aetnamedicare.com).
Prescriber may request an appeal for the enrollee; to appoint another representative, call 1-866-235-5660.
To request expedited review, check the expedited box and attach a prescriber supporting statement; if prescriber affirms harm from waiting 7 days, decision will be made within 72 hours.
Expedited review is not available for requests solely to be reimbursed for a drug already obtained.

Key Terms

Expedited appeal

DefinitionExpedited (fast) decision: an appeal processed within 72 hours when waiting 7 days for a standard decision could seriously harm life, health, or ability to regain maximum function.

When to requestRequest expedited review if you believe you need a decision within 72 hours or if waiting 7 days could seriously harm your life, health, or ability to regain maximum function.

Prescriber supportIf your prescriber indicates waiting 7 days could seriously harm your health, Aetna will automatically give you a decision within 72 hours; if no prescriber support, Aetna will determine if a fast decision is required.

LimitationsExpedited appeals are not available for requests that are solely reimbursement for a drug already obtained.

Representative

DefinitionRepresentative: a person authorized to act on behalf of the enrollee; must attach documentation showing authority (for example, Form CMS-1696 or written equivalent) if not previously submitted.

When to completeComplete the representative section only if the person making the request is not the enrollee or the enrollee's prescriber.

Required detailsProvide representative name, relationship to enrollee, street address, city/state/ZIP, and phone number on the form.

How to get helpFor more information on appointing a representative, call 1-866-235-5660.