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Aetna Medicare


Medicare Prescription Processing/Denials/Appeals

Complaint Rating:  100 % with 12 votes
100% 12
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United States
My mother started her Medicare Part D plan in 2008. I retained Aetna for her in 2009 and I still kept them in 2010. Despite knowing the changes in their Drug Formulary, there was no need to change plans given I was ASSURED that my mothers' prior authorizations would still cover 4 medications - in writing. For those who do not know, a Preferred Drug Formulary is their "list" of drugs they will cover and at what price "Tier", Brand vs. Generic, etc. These 4 medications were covered in 2008 and 2009 via the "prior authorizations", hence the need for these prior authorizations which allowed her to get the medications for 3 years. All I did was confirm and ensure that these were, in fact, still valid to which I have correspondence that it was.

So January RX refill time comes around and I fill everything for her (14 scripts total) without a problem. 3 weeks and 2 days later, I receive a letter stating one of her RX's was filled as a "One-Time Courtesy" and she needs to find a "preferred" drug that is similar OR obtain a Prior Authorization! Mind you, as stated above, I CONFIRMED with them that her prior authorizations would STILL be in effect until August 31st 2011.

The next day, another letter, same reason, different drug. Next day, 2 letters this time (separate envelopes - could have saved a stamp given these were all filled the same day and all the letters had the same date - go figure). Now, I have letters stating ALL FOUR of the medications, already approved via Prior Authorizations, were no longer covered!! Confused yet? Good - you should be; that was AETNA'S purpose. Nevertheless, ALL four letters are contrary to the APPROVAL correspondence stating (all 4 medications) are COVERED FROM AUGUST 01, 2010 - AUGUST 31, 2011.

AETNA did this as a tactic, to lock-in my mother for ANOTHER year, knowing full well that on January 1st of EACH YEAR, ANY PRIOR "PRIOR AUTHORIZATIONS" BECOME NULL & VOID!!! I was NEVER told this, ALL letters say otherwise, this did not happen when we went from 2009-2010, and let us not forget the APPROVED UNTIL AUGUST 31, 2011!!

Then the phone calls to AETNA started - of course not ONE person was helpful until the very end, approximately 35 reps, 3 supervisors, and 2 1/2 weeks later. Let's not forget too that these "We changed our minds" letters came only DAYS before her medications were due to be refilled come February.

Her doctor and I had to BOTH file an expedited appeal for a formulary exception, which basically asks AETNA to cover it even though it's not on the Formulary. This was denied stating "PATIENT MUST UTILIZE 2 OTHER LONG-ACTING MEDICATIONS OVER A 90 DAY PERIOD BEFORE WE CAN CONSIDER A FORMULARY EXCEPTION". Before they would cover the drug again??? Ummm - this is why we had these approved already - so now AETNA wants my mother to go backwards, suffer tremendously for 3 months, in order to "prove" that they do not work? Upon speaking with them about this "denial", I advised that my mother already went through this, that's why we have the Prior Authorizations, and yet I am told that is NOT SUFFICIENT since this did not occur in the last 6 months!!! WHY WOULD IT? SHE HAD AUTHORIZATIONS FOR THE MEDICATIONS THAT DO WORK!! Now what must I do? Appeal time - and not just a regular one, an "expedited" one since we're down to LESS THAN A WEEK before she is out completely.

Nevertheless, in my 10-page appeal as well as through her physician giving me time in his office to back up the statements with medical data, ALL of this was outlined. ALL was faxed, I printed the confirmation, and even contacted them to ensure it was received. I was told yes and the doctor, who had also called the day after, was also told ALL info needed was received. 2 days later, I get a phone call stating NEITHER THE DOCTOR NOR I, ON BEHALF OF MY MOTHER, SUBMITTED RECORDS/RATIONALE WITHIN 48 HOURS!! This is when the phone-wars began. I miraculously found a manager, who just happened to get suckered into the phone call in my opinion, gave me a DIRECT fax number, I faxed all my stuff and the doctor's stuff to her while on the phone, she cofirmed receipt and faxed a signature page back to me indicating 52 pages were received, and she forwarded this to the person handling the appeal.

THE DAY AFTER her medications ran out, I got a phone call indicating the appeal(s) had been approved. While this is good news of course, the fact is that I had the chance to AVOID ALL OF THIS ENTIRELY HAD WRITTEN CORRESPONDENCE BEEN HONORED FROM THE START!!! Obviously AETNA had no leg to stand on when the only dates I have refer to an expiration of August 2011; NO WHERE does it state that the "New Year" would "void" the "prior" prior authorizations. To add insult to injury, however, it then came to my attention that I neglected to handle the "quantity limitations" on the other 2 medications. SO, I guess AETNA already knew once they heard my name that it's best to just fix it NOW, i did not have to go through all that hell AGAIN for the remaining two medications.

The point of all this?
#1: Especially when you are dealing with elderly people or worse, those who are experiencing dementia or Alzheimer's, the HUGE book you get when open-enrollment starts every November is enough for the SMARTEST OF THE SMART to be confused!!
#2: DECEPTIVE TRADE PRACTICES - Sending out not one, not two, not three, but FOUR different letters for FOUR different medications with FOUR different approvals and then turning around and DENYING they are valid due to the standard "Start of a New Year" line of BS.
#3: Waiting until the patient is ALMOST OUT OF MEDICATION to advise them there will be an issue of non-coverage.
#4: Trying to make an old woman suffer, without just cause or god-forbid HUMANITY, by attempting to demand her to take medications that are known to NOT work and cause major side-effects, for THREE MONTHS before 'considering' approval of the Exception.
#5: Having to turn myself into a Lawyer, basically, in order to put together EVERY SHRED of documentation possible, while sitting with and LITERALLY spending time at her Doctor's office with her physician to write out all these explanations and "chronologies" and "How AETNA is blatantly WRONG". I mentioned the lawyer part as I quoted EVERY piece of legal mumbo-jumbo THEY USED ON MY MOTHER to use for my Mother's advantage. Given the coverage under the policy is, afterall, a Contract, that means I will just throw the legal mumbo-jumbo right back at AETNA.
#6: Make this ALL HAPPEN within 4 or 5 days that never would have happened if I was just told, back in November, that in order for my mother's Prior Authorizations to be valid starting on January 1st 2011, I would need to start the process THEN instead of having to scramble for 4 days, non-stop, before she ran out of medications.

HOW can ANYONE sleep at night knowing they are putting others' lives in jeopardy EVERY SINGLE DAY OVER THE ALMIGHTY DOLLAR???? What is wrong with this country that companies are ALLOWED to hurt people? This is not just about my mother - this is about ALL our elderly, disabled, or retired people who have Medicare, specifically Aetna's Medicare Prescription plan. I can't emphasize these points enough over how deceptive AETNA has been. Here I think I'm being proactive in regards to my mother's health and what happens? CATASTROPHE.

People beware - and I DO NOT - I repeat DO NOT say this as an insult in the least but have others help you even if you think/believe/advised your plan is FINE. Whether you're 65 or 85, they WILL TRY to throw you under the bus and you'll be left with NOTHING! If myself, my mother's Doctor, and her Doctor's attorney had issues resolving what should have been a VERY simple matter, I can only imagine, as well as FULLY understand, what has been done to others. Luckily and with ALOT of prayer, the wool did not get pulled over MY eyes from these idiots looking for suckers to just "give in" and allow them to have their salaries and other perks. I wonder if they get bonuses for MORE denials?? Surely that's the case otherwise what is the incentive to cause THIS much grief for people?

Imagine this being your elderly mother, father, aunt, uncle, neighbor, and/or friends having THEIR medical needs just ripped from underneath them. SAD THAT PEOPLE DILIGENTLY WORK HARD AT FINDING WAYS TO MAKE THESE PEOPLE SUFFER ALL FOR THE SAKE OF THE ALMIGHTY DOLLAR!!! Then imagine having to put together a HUGE presentation for them in 72 hours or you're screwed. Like I said so many times - WHY was I not told THEN instead of NOW? Retention via Deception!!!

Complaint comments Comments (1) Complaint country United States Complaint category Health & Life Insurance


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A  7th of Sep, 2012 by    +1 Votes
Call 1-800-MEDICARE to report them. They do not want you to do this!!! Just to check, call Aetna Medicare and ask them for the number to actual MEDICARE. They will say that they do not have the number. They do, they just don't want you to call. How do I know? I was a representative with them for 4 years. Aetna was sanctioned by MEDICARE for over a year, and they deserve it even longer.

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