Aetna Medicare Transition of Coverage (Part D) process
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Defines Aetna Medicare's process to provide temporary transition supplies for Part D drugs not on formulary or subject to new utilization management requirements, and explains member rights, procedures, and appeals. Applies to new and continuing Aetna Medicare members nationwide.
No material clinical or coverage changes in this revision.
Transition Supply Coverage & Requirements
Transition supply coverage criteria and follow-up steps
Covered when ALL of the following apply:
The 90-day transition period also applies during the plan year if a drug is removed from the formulary.
For long-term care residents, maximum single transition fill is 31 days.
Provider submission may include clinical information to request prior authorization, formulary exception, step therapy removal, or quantity limit removal.
Decision timeframes apply after the Precertification Unit has received the physician's statement/clinical information.
Provider Submission, Documentation, and Authorization Process
Submit physician statement and clinical information to Precertification Unit
Provider may submit a written physician's statement and supporting clinical information to the Precertification Unit to request prior authorization, a formulary exception, removal of step therapy, or removal of a quantity limit. Requests may be faxed, mailed, or called in; if called in, the doctor should follow up by faxing or mailing the signed statement.
- Submit a signed written doctor's (physician's) statement explaining the medical reasons for the exception.
- Contact Precertification Unit by mail, fax, or telephone—follow telephone requests with a faxed or mailed signed statement.
- Requests may ask for prior authorization, formulary exception, step therapy removal, or quantity limit removal.
- Decision timeframes after receipt of physician's statement: 24 hours for expedited requests and 72 hours for standard requests.
Key Terms and Definitions
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