By Counterforce Health Team in Synagis (palivizumab) —

Get Synagis (Palivizumab) Covered by Aetna CVS Health in Pennsylvania: 2024 Forms, Appeals & Contact Guide

Quick Start: Getting Synagis Approved by Aetna CVS Health in Pennsylvania

Most important step: Complete Aetna's Synagis precertification form and submit via fax (1-888-267-3277) or phone (1-866-752-7021). Key requirement in 2024: Aetna now requires documentation that Beyfortus (nirsevimab) is contraindicated, unavailable, or ineffective before approving Synagis. Eligible high-risk infants include those born <29 weeks gestational age (if <12 months old at RSV season start) or those with chronic lung disease, severe immunodeficiency, or cardiac transplant history. If denied, you have 180 days to appeal internally, then 4 months to request Pennsylvania's state external review, which overturns ~50% of denials.

Table of Contents

  1. Verify Your Plan and Find Current Forms
  2. Required Prior Authorization Forms
  3. Submission Portals and Online Access
  4. Fax Numbers and Mailing Addresses
  5. CVS Specialty Pharmacy Enrollment
  6. Support Phone Lines and What to Ask
  7. Pennsylvania State Appeals and Consumer Help
  8. When to Check for Updates

1. Verify Your Plan and Find Current Forms

Before starting any prior authorization process, confirm your exact Aetna plan type. Commercial plans, Medicare Advantage, and Medicaid managed care each have different forms and submission processes.

Plan Verification Steps:

  • Check your insurance card for "Aetna" or "CVS Health" branding
  • Log into your member portal at Aetna.com to view your specific formulary
  • Verify Synagis is covered under your plan's medical benefit (not pharmacy benefit)
  • Confirm you're in Pennsylvania for state-specific appeal rights

Current Policy Requirements (2024): According to Aetna's clinical policy bulletin #0318, Synagis is only approved when Beyfortus (nirsevimab) is not clinically appropriate. This represents a significant change from previous years when both medications had similar approval criteria.

2. Required Prior Authorization Forms

Primary Form: Synagis Precertification Request

  • Official form title: "Synagis® (palivizumab) Injectable Medication Precertification Request"
  • Download link: Aetna Synagis PA Form (PDF)
  • Key sections to complete:
    • Patient demographics and insurance information
    • Clinical justification for why Beyfortus is not appropriate
    • Gestational age, chronological age, and qualifying diagnosis
    • Prescriber signature and NPI number

Clinical Documentation Checklist:

  • Birth certificate or hospital records showing gestational age
  • Medical records documenting qualifying condition (prematurity, chronic lung disease, immunodeficiency, cardiac transplant)
  • Documentation of contraindication to or failure of Beyfortus
  • Current weight for dosing calculations
  • Cardiology or pulmonology consultation notes (if applicable)
Clinician Corner: Medical necessity letters should explicitly address why Beyfortus is not suitable for this patient. Common acceptable reasons include documented allergic reaction to nirsevimab, supply shortage at your facility, or clinical scenario where monthly dosing is preferred over single-dose prophylaxis.

3. Submission Portals and Online Access

Availity Provider Portal (Recommended)

  • Website: Availity.com
  • What it offers: Real-time PA submission, status tracking, and automated approvals for some requests
  • Setup required: Provider enrollment and credentialing (allow 2-3 weeks for initial setup)
  • Upload capability: Attach clinical notes, lab results, and imaging directly to requests

Member Portal Submission

  • Patients can submit appeals through their Aetna member portal
  • Less efficient than provider portal but available 24/7
  • Useful for uploading additional documentation during appeals

4. Fax Numbers and Mailing Addresses

Prior Authorization Fax Lines:

  • Primary PA fax: 1-888-267-3277
  • Phone submission: 1-866-752-7021 (TTY: 711)
  • Provider support: 1-888-632-3862

Mailing Address for Appeals:

Aetna
Attn: Appeals Department
P.O. Box 14079
Lexington, KY 40512-4079

Cover Sheet Best Practices:

  • Include "URGENT - RSV SEASON" if submitting during peak season (October-March)
  • List all attached pages and document types
  • Include prescriber's direct phone number for peer-to-peer reviews
  • Mark "EXPEDITED" if patient has active RSV infection or high-risk hospitalization

5. CVS Specialty Pharmacy Enrollment

Many Aetna plans require Synagis to be dispensed through CVS Specialty Pharmacy. Here's the enrollment process:

Enrollment Steps:

  1. Complete enrollment form: CVS Specialty RSV Enrollment Form
  2. Fax completed form: 855-264-7856
  3. Include required documents:
    • Copy of insurance cards (front and back)
    • Completed prior authorization form
    • Clinical documentation supporting medical necessity

Transfer from Another Pharmacy:

  • CVS Specialty can coordinate prescription transfers
  • Provide previous pharmacy contact information on enrollment form
  • Allow 3-5 business days for transfer completion
  • Confirm no gap in therapy during RSV season

CVS Specialty Contact Information:

6. Support Phone Lines and What to Ask

Aetna Member Services: 1-800-872-3862

  • Ask for: Current PA status and any missing documentation
  • Best times to call: Weekday mornings (8-10 AM ET)
  • Have ready: Member ID, PA reference number, prescriber NPI

Provider Relations: 1-888-632-3862

  • Ask for: Peer-to-peer review scheduling
  • Request: Medical director contact for complex cases
  • Escalation: Supervisor if initial denial seems inappropriate

Key Questions to Ask:

  • "What specific clinical criteria is missing from our submission?"
  • "Can you schedule a peer-to-peer review with the medical director?"
  • "What is the exact deadline for submitting additional documentation?"
  • "Is this covered under medical or pharmacy benefits?"

7. Pennsylvania State Appeals and Consumer Help

Pennsylvania offers robust consumer protections for health insurance appeals, including a state-run external review program that overturns approximately 50% of denials.

Pennsylvania External Review Process:

  1. Complete Aetna's internal appeals first (required)
  2. File external review within 4 months of final denial letter
  3. Submit through multiple channels:

Required Documents for External Review:

  • Final Adverse Benefit Determination letter from Aetna
  • Copy of insurance card
  • Medical records supporting necessity
  • Physician certification form (for expedited reviews)

Timeline Expectations:

  • Standard review: 45 days for decision
  • Expedited review: 72 hours (for urgent cases)
  • Success rate: ~50% of appeals are overturned in favor of patients

Free Consumer Assistance:

  • Pennsylvania Health Law Project: Provides free help with complex appeals
  • Pennsylvania Insurance Department Consumer Services: 1-877-881-6388
  • Pennie (PA Marketplace) Consumer Hotline: For marketplace plan issues
From Our Advocates: We've seen families successfully overturn Synagis denials by emphasizing the child's specific risk factors and providing detailed documentation of why Beyfortus wasn't appropriate. One case involved a premature infant with chronic lung disease where the family's pediatric pulmonologist provided a detailed letter explaining the benefits of monthly monitoring that comes with Synagis administration. The external review overturned the denial within 30 days.

8. When to Check for Updates

Healthcare coverage policies change frequently. Here's when to verify information:

Annual Updates (January):

  • New prior authorization requirements
  • Updated formulary status
  • Changes to step therapy protocols
  • Revised appeal deadlines

Seasonal Updates (August-September):

  • RSV season preparation guidelines
  • Updated CDC/AAP recommendations
  • Supply availability for Beyfortus vs. Synagis

Ongoing Monitoring:

Coverage at a Glance

Requirement Details Where to Find Source
Prior Authorization Required for all plans PA form required Aetna Policy #0318
Eligible Age <12 months (premature) or <24 months (CLD) Clinical criteria section Aetna Policy #0318
Maximum Doses 5 doses per RSV season Dosing limitations Aetna Policy #0318
Beyfortus Requirement Must document why not appropriate PA form section 3 Aetna Policy #0318
Appeal Deadline 180 days internal, 4 months external Member handbook PA External Review

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take in Pennsylvania? Standard decisions are made within 30-45 days. Expedited reviews for urgent cases are typically completed within 72 hours, especially during RSV season.

What if Synagis is not on my plan's formulary? You can request a formulary exception by providing medical necessity documentation. Include evidence that Beyfortus is not appropriate and that Synagis is the only suitable alternative.

Can I request an expedited appeal if my child has active RSV? Yes. Contact Aetna immediately at 1-800-872-3862 and request an expedited review. Provide documentation from your child's physician confirming the urgent medical need.

Does step therapy apply to Synagis in Pennsylvania? Yes, Aetna's 2024 policy requires trying or documenting why Beyfortus is inappropriate before approving Synagis. This is considered step therapy.

What happens if I pay out-of-pocket during an appeal? If your appeal is successful, Aetna must reimburse you for covered expenses. Keep all receipts and submit them with your reimbursement request.

How much does Synagis cost without insurance? The wholesale acquisition cost is approximately $1,820 per 50mg vial as of January 2025. Most children require multiple doses throughout RSV season.

Cost Assistance Options

Manufacturer Support:

  • Sobi/AstraZeneca may offer patient assistance programs
  • Contact manufacturer directly for current eligibility criteria
  • Income-based assistance may be available

State Programs:

  • Pennsylvania's Children's Health Insurance Program (CHIP) may cover eligible families
  • Medicaid coverage available for qualifying low-income families

Common Denial Reasons and Solutions

Denial Reason Solution Strategy
"Not high-risk enough" Provide detailed birth records, NICU notes, and specialist consultations
"Beyfortus should be used instead" Document contraindication, allergy, or supply shortage
"Exceeds dose limits" Justify need for full 5-dose regimen with RSV season timeline
"Lack of specialist documentation" Obtain pulmonology or cardiology consultation

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. The platform analyzes denial letters, identifies the specific denial basis, and creates evidence-backed appeals that align with each payer's own policies and procedures.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for the most current coverage requirements. Coverage policies may vary by plan type and can change without notice. For personalized assistance with complex appeals, consider consulting with Counterforce Health or other healthcare advocacy services.

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