By Counterforce Health Team in HyperHEP (hepatitis B immune globulin) —

Do You Qualify for HyperHEP (hepatitis B immune globulin) Coverage by Aetna (CVS Health) in Pennsylvania? Decision Tree & Next Steps

Answer Box: Getting HyperHEP Covered by Aetna (CVS Health) in Pennsylvania

Yes, HyperHEP (hepatitis B immune globulin) is covered by Aetna (CVS Health) in Pennsylvania with prior authorization. The fastest path: 1) Document exposure details and patient's anti-HBs status (<10 mIU/mL), 2) Submit PA through Availity portal within 24-48 hours of exposure, 3) Mark as urgent for post-exposure prophylaxis. If denied, Pennsylvania's new external review program overturns about 50% of appeals. Start with your exposure documentation today.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible" - Your Action Plan
  4. If "Possibly Eligible" - Tests & Timeline
  5. If "Not Yet" - Alternatives & Exceptions
  6. If Denied - Pennsylvania Appeal Process
  7. Decision Flowchart
  8. Resources & Verification

How to Use This Decision Tree

This guide helps you determine if you qualify for HyperHEP (hepatitis B immune globulin) coverage through Aetna (CVS Health) in Pennsylvania. Start by identifying your exposure scenario below, then follow the specific pathway.

For emergent post-exposure situations (needlestick, sexual assault, newborn of HBsAg-positive mother), don't wait for this process—seek immediate medical care. Hospital pharmacies can dispense HyperHEP emergently with retroactive prior authorization.

Note: This applies to Pennsylvania-regulated Aetna commercial and Medicare plans. Self-funded employer plans may have different requirements.

Eligibility Triage: Do You Qualify?

Check Your Exposure Category

Likely Eligible (High Priority)

  • Percutaneous exposure (needlestick) to HBsAg-positive blood within 7 days
  • Infant born to HBsAg-positive mother (within 12 hours of birth)
  • Sexual exposure to HBsAg-positive partner within 14 days
  • Liver transplant recipient requiring HBV prophylaxis protocol

Possibly Eligible (Needs Documentation)

  • Exposure to unknown HBsAg status but high-risk source
  • Previously vaccinated but anti-HBs <10 mIU/mL (non-responder)
  • Healthcare worker exposure >7 days but <14 days ago
  • Household contact of acute hepatitis B case

Not Yet (Alternative Approach Needed)

  • Exposure >14 days ago (limited HBIG effectiveness)
  • Previously vaccinated with anti-HBs ≥10 mIU/mL (immune)
  • No documented exposure or source testing

Required Documentation Checklist

Requirement What You Need Where to Find It
Exposure Details Date, time, type of contact Incident report, medical record
Source HBsAg Status Positive test or high-risk profile Lab report, source patient chart
Patient Immunity Anti-HBs <10 mIU/mL or unvaccinated Recent lab work, vaccination record
Timing Documentation Hours/days since exposure Medical record, incident timeline
Weight-Based Dosing Patient weight for 0.06 mL/kg calculation Current medical record

If "Likely Eligible" - Your Action Plan

Step 1: Gather Required Documents (Day 1)

  • Exposure documentation: incident report with date/time/circumstances
  • Source HBsAg lab: positive result or high-risk documentation
  • Patient serology: anti-HBs level (<10 mIU/mL indicates susceptibility)
  • Vaccination history: previous hepatitis B vaccine series completion

Step 2: Submit Prior Authorization Immediately

Submission Method: Aetna Availity Portal or NovoLogix for specialty drugs

Required Elements in PA Request:

  • Mark as URGENT for post-exposure prophylaxis
  • Include CDC/ACIP guideline reference supporting timing
  • Attach all documentation from Step 1
  • Calculate exact dose: 0.06 mL/kg IM
  • Note concurrent hepatitis B vaccination plan

Step 3: Track Decision Timeline

Clinician Corner: Include in your medical necessity letter: "Per CDC ACIP guidelines, HBIG is recommended for post-exposure prophylaxis in susceptible individuals exposed to HBsAg-positive materials, ideally within 24 hours. Patient meets criteria with documented exposure on [date] and anti-HBs <10 mIU/mL."

If "Possibly Eligible" - Tests & Timeline

Additional Testing Needed

  1. Source patient HBsAg testing (if not already done)
  2. Complete hepatitis B panel for exposed person:
    • HBsAg, anti-HBs, anti-HBc
    • Vaccination history verification

Documentation to Strengthen Your Case

  • High-risk source profile if HBsAg unknown (injection drug use, multiple partners, healthcare exposure)
  • Previous vaccine non-response documentation if applicable
  • Clinical urgency statement explaining why delay increases infection risk

Timeline for Resubmission

  • Within 7 days of exposure for optimal HBIG effectiveness
  • Up to 14 days for sexual exposures per CDC guidelines
  • Beyond 14 days: Consider vaccine-only approach unless special circumstances

If "Not Yet" - Alternatives & Exceptions

Alternative Approaches

  1. Hepatitis B vaccine series alone (if >7-14 days post-exposure)
  2. Medical exception request for late presentation with compelling circumstances
  3. Specialist consultation (infectious disease, hepatology) for complex cases

Exception Request Strategy

When standard criteria aren't met, submit a medical exception with:

  • Specialist letter supporting HBIG use despite timing
  • High-risk patient factors (immunocompromised, pregnancy, etc.)
  • Literature support for extended window in special populations

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals that align with payer requirements and clinical guidelines.

If Denied - Pennsylvania Appeal Process

Pennsylvania launched its Independent External Review Program in January 2024, with about 50% of appeals overturning insurer denials.

Internal Appeal Process (First Step)

  1. File within 180 days of denial letter
  2. Submit through Aetna member portal or written appeal
  3. Include additional evidence:
    • Updated medical necessity letter
    • Missing lab results or exposure documentation
    • Peer-reviewed literature supporting HBIG use
  4. Request peer-to-peer review if medical necessity was questioned

Pennsylvania External Review (After Internal Appeals)

Timeline: Must request within 4 months of Final Adverse Benefit Determination

Process:

  • Standard review: Decision within 45 days of IRO assignment
  • Expedited review: Decision within 72 hours for urgent cases
  • 15-day window to submit additional evidence after IRO assignment

Success Rate: Pennsylvania reports 259 of 517 appeals (50.1%) were overturned in 2024

From Our Advocates: We've seen post-exposure HBIG appeals succeed when providers emphasize the narrow time window for effectiveness and cite specific CDC guidance tables. Include the exact exposure scenario (e.g., "Table 2, CDC MMWR 2006") that matches your patient's situation.

Decision Flowchart

Start Here: Exposure to HBV? ↓ Yes Source HBsAg-positive or high-risk? ↓ Yes Patient anti-HBs <10 mIU/mL or unvaccinated? ↓ Yes Within 7 days (percutaneous) or 14 days (sexual)? ↓ Yes → LIKELY ELIGIBLE: Submit urgent PA

→ If No at any step: Follow "Possibly Eligible" or "Not Yet" pathways above

Resources & Verification

Official Aetna Resources

Pennsylvania Insurance Resources

Clinical Guidelines

Frequently Asked Questions

How long does Aetna prior authorization take in Pennsylvania? Aetna reports >95% of eligible PAs are approved within 24 hours. Urgent post-exposure requests are typically decided within 72 hours.

What if HyperHEP is non-formulary on my plan? Submit a formulary exception with medical necessity documentation. Include CDC guidelines and lack of suitable alternatives for post-exposure prophylaxis.

Can I request an expedited appeal in Pennsylvania? Yes, if waiting for standard review could seriously jeopardize your health. Pennsylvania's expedited external review provides decisions within 72 hours.

Does step therapy apply to post-exposure HBIG? Generally no, since HBIG has unique timing requirements and no therapeutic alternatives for post-exposure prophylaxis. If step therapy is cited, request immediate exception based on clinical urgency.

What if I'm uninsured or underinsured? Check Grifols patient assistance programs for income-qualified patients. Some programs cover up to 250% of federal poverty level.

For complex denials or appeals, Counterforce Health's platform helps transform insurance rejections into evidence-based appeals by analyzing plan policies and crafting targeted rebuttals that address specific denial reasons.

Disclaimer: This information is for educational purposes only and is not medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For assistance with appeals in Pennsylvania, contact the Pennsylvania Insurance Department Consumer Services or consult with qualified legal counsel.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.