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Request for Redetermination of Medicare Prescription Drug Denial

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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.

Provide prescription and prescriber information: name of drug (including strength/quantity/dose), prescriber name, office address, city/state/ZIP, office phone, office fax, and office contact person.

Submission options and contact information: you may file the appeal using the form, online at www.aetnamedicare.com, by mail, or by fax; expedited appeal requests may be made by phone at 1-866-235-5660.

Expedited request requirements: check the expedited request option and attach a supporting prescriber statement if you believe waiting for a standard decision could seriously harm the enrollee — expedited requests are handled within 72 hours when justified (prescriber support can trigger expedited handling).

Representative information: if someone other than the enrollee or the enrollee's prescriber files the appeal, provide representative documentation and follow instructions to name a representative by calling 1-866-235-5660.

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.

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

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Request for Redetermination of Medicare Prescription Drug Denial

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Sign up for all Aetna policy alerts

Know when Aetna releases new policies or updates existing guidance.

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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).

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.

Provide prescription and prescriber information: name of drug (including strength/quantity/dose), prescriber name, office address, city/state/ZIP, office phone, office fax, and office contact person.

How to Request a Redetermination / Expedited Review

Prior Authorization

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

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.

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

Representative

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.

OpenPayer

Request for Redetermination of Medicare Prescription Drug Denial

Sign up for all Aetna policy alerts

Documentation and Submission Requirements

How to Request a Redetermination / Expedited Review

Key Terms

Catch payer policy changes before they impact reimbursement

Catch payer policy changes before they impact reimbursement

OpenPayer

Request for Redetermination of Medicare Prescription Drug Denial

Sign up for all Aetna policy alerts

Documentation and Submission Requirements

How to Request a Redetermination / Expedited Review

Key Terms