By Counterforce Health Team in Cresemba (isavuconazole) —

Get Cresemba (Isavuconazole) Covered by Aetna CVS Health in Washington: Forms, Appeals & Support

Answer Box: Getting Cresemba Covered by Aetna CVS Health in Washington

Yes, Aetna CVS Health covers Cresemba (isavuconazole) with prior authorization for invasive aspergillosis and mucormycosis. The fastest path: submit a complete PA request through CVS Caremark's electronic portal with diagnosis documentation, prior antifungal trials, and infectious disease consultation notes. If denied, you have 180 days to appeal internally, then request external review through Washington's Office of the Insurance Commissioner. Start today: verify your plan's formulary status and gather clinical documentation.

Table of Contents

  1. Verify Your Plan & Coverage
  2. Prior Authorization Forms & Requirements
  3. Submission Portals & Electronic Options
  4. Fax Numbers & Mailing Addresses
  5. CVS Specialty Pharmacy Enrollment
  6. Provider & Member Support Lines
  7. Appeals Process in Washington State
  8. When to Contact Washington Regulators
  9. Update Schedule & Resources

1. Verify Your Plan & Coverage

Before requesting prior authorization, confirm Cresemba's status on your specific Aetna plan. Coverage varies between commercial, Medicare, and Medicaid products.

What to Check:

  • Log into your Aetna member portal or call the number on your insurance card
  • Search for "Cresemba" or "isavuconazole" in the formulary tool
  • Note the tier level (typically Tier 3-4 specialty)
  • Check if step therapy requirements apply
Tip: Most Aetna plans require prior authorization for Cresemba regardless of tier status due to its specialty classification.

Coverage at a Glance:

Requirement Details Where to Find
Prior Authorization Required for all indications Aetna formulary search
Step Therapy May require voriconazole trial first PA form clinical questions
Quantity Limits Based on FDA dosing (loading then maintenance) Plan documents
Site of Care Hospital or specialty pharmacy CVS Specialty enrollment

2. Prior Authorization Forms & Requirements

Aetna requires comprehensive clinical documentation for Cresemba approval. The PA process typically takes 5-7 business days for standard requests.

Required Documentation:

  • Confirmed or probable diagnosis of invasive aspergillosis or mucormycosis
  • ICD-10 codes (B44.0-B44.9 for aspergillosis, B46.0-B46.9 for mucormycosis)
  • Prior antifungal therapies attempted and outcomes
  • Infectious disease specialist consultation (often required)
  • Laboratory/imaging evidence supporting diagnosis
  • Clinical rationale if voriconazole cannot be used

Medical Necessity Criteria:

  • FDA-approved indication (invasive aspergillosis or mucormycosis)
  • No contraindications to isavuconazole
  • Documentation of treatment duration and monitoring plan
  • For off-label use: peer-reviewed literature support required
Clinician Corner: Include specific details about prior therapy failures, such as "voriconazole discontinued after 5 days due to visual disturbances" rather than simply "voriconazole intolerance."

3. Submission Portals & Electronic Options

Electronic submission through CVS Caremark's portal is fastest and provides real-time status updates.

CVS Caremark Electronic Prior Authorization (ePA):

  • Access through the CVS Caremark provider portal
  • Compatible with most EHR systems
  • Upload supporting documents directly
  • Automated decisions possible for straightforward cases

Submission Steps:

  1. Register for CVS Caremark ePA portal (if not already registered)
  2. Select "Cresemba" or "isavuconazole" from drug list
  3. Complete clinical questionnaire
  4. Upload all supporting documentation
  5. Submit and track status online

For Urgent Cases:

  • Mark as "urgent" if patient's health is at immediate risk
  • Include clinical justification for urgency
  • Expedited decisions typically within 72 hours

4. Fax Numbers & Mailing Addresses

When electronic submission isn't available, use these verified contact methods:

CVS Specialty Pharmacy:

  • Provider Support Phone: 1-877-242-2738
  • Prescription/Enrollment Fax: 1-877-943-1000

Aetna Prior Authorization:

  • General PA Fax: 1-800-323-2445
  • Specialty Medications: Use CVS Caremark contacts above

Cover Sheet Tips:

  • Include "URGENT" prominently if applicable
  • List all pages being faxed
  • Include return fax number for questions
  • Reference member ID and drug name clearly

5. CVS Specialty Pharmacy Enrollment

Cresemba is typically dispensed through CVS Specialty Pharmacy once prior authorization is approved.

Enrollment Process:

  1. Complete CVS Specialty enrollment form (available on their website)
  2. Fax completed form to 1-877-943-1000
  3. Include front and back of insurance card
  4. Provide complete prescriber information

Required Information:

  • Patient demographics and insurance details
  • Prescriber NPI and contact information
  • Prescription details matching PA approval
  • Preferred delivery address and contact method

Transfer from Another Pharmacy:

  • CVS Specialty can coordinate transfers
  • Call 1-877-242-2738 for transfer assistance
  • Ensure PA approval transfers with prescription

6. Provider & Member Support Lines

For Providers:

  • CVS Caremark Provider Services: 1-877-408-9742
  • Aetna Provider Line: Check your provider manual for current number
  • Prior Authorization Status: Available through online portals

For Members:

  • Aetna Customer Service: Number on back of insurance card
  • CVS Specialty Patient Support: Provided after enrollment
  • Pharmacy Benefits Questions: 1-877-408-9742

What to Ask When Calling:

  • Current PA status and any missing documentation
  • Expected decision timeline
  • Appeal rights if denied
  • Specialty pharmacy enrollment status

7. Appeals Process in Washington State

Washington provides strong consumer protections for insurance denials, including external review rights.

Internal Appeals with Aetna:

  • First Level: Submit within 180 days of denial
  • Standard Timeline: 30 days for decision
  • Expedited Appeals: 72 hours for urgent cases
  • Required: Use Aetna's appeal form and include all supporting evidence

External Review in Washington:

  • Available after exhausting internal appeals
  • Timeline: 180 days from final internal denial to request
  • Process: Washington Office of the Insurance Commissioner assigns Independent Review Organization (IRO)
  • Decision: Binding on Aetna if overturned

Step-by-Step Appeal Process:

  1. Gather Documentation: Denial letter, medical records, treatment history
  2. Submit Internal Appeal: Use Aetna's process (form on denial letter)
  3. Await Decision: 30 days standard, 72 hours expedited
  4. Request External Review: If still denied, contact Washington OIC
  5. IRO Review: Independent medical experts review case
  6. Final Decision: Binding determination within 30 days

8. When to Contact Washington Regulators

The Washington Office of the Insurance Commissioner (OIC) provides free assistance to consumers facing insurance denials.

Washington OIC Contact Information:

  • Consumer Help Line: 1-800-562-6900
  • External Review Requests: Online at insurance.wa.gov or fax (360) 586-2018
  • Mailing Address: Washington State Office of the Insurance Commissioner P.O. Box 40255 Olympia, WA 98504-0255

When to Contact OIC:

  • After exhausting Aetna's internal appeals
  • If Aetna doesn't respond within required timelines
  • For help understanding your appeal rights
  • To file a complaint about unfair claim practices

Counterforce Health specializes in turning insurance denials into successful appeals by creating targeted, evidence-backed responses that align with each payer's specific requirements. Our platform ingests denial letters and plan policies to draft point-by-point rebuttals supported by FDA labeling, peer-reviewed studies, and clinical guidelines—helping patients and providers navigate complex prior authorization processes more effectively.

9. Update Schedule & Resources

Insurance policies and forms change regularly. Here's how to stay current:

Quarterly Checks:

  • Review Aetna formulary updates
  • Verify current PA forms and requirements
  • Check for new submission portal features

Annual Reviews:

  • Washington state law changes
  • OIC external review process updates
  • CVS Specialty contact information

Key Resources to Bookmark:

Frequently Asked Questions

How long does Aetna prior authorization take for Cresemba? Standard PA requests typically take 5-7 business days. Expedited requests for urgent cases are decided within 72 hours.

What if Cresemba is non-formulary on my plan? Request a formulary exception with clinical documentation showing medical necessity and that preferred alternatives are inappropriate.

Can I get an expedited appeal in Washington? Yes, if your health could be seriously jeopardized by waiting for a standard appeal timeline. Both Aetna and Washington's external review process offer expedited options.

Does step therapy apply if I failed voriconazole outside Washington? Yes, document prior therapy failures regardless of where they occurred. Include medical records and provider notes about the failure or intolerance.

What happens if the external review upholds Aetna's denial? The IRO decision is binding, but you can still contact the Washington OIC for guidance on other options or file a complaint if you believe the process was flawed.

For complex cases or repeated denials, Counterforce Health helps create comprehensive appeals that address payer-specific requirements and increase approval rates through targeted clinical evidence and procedural expertise.

Sources & Further Reading

This information is for educational purposes only and does not constitute medical or legal advice. Always consult with healthcare providers and insurance representatives for specific guidance regarding your situation. Coverage policies and procedures may vary by plan and change over time.

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