By Counterforce Health Team in Berinert (C1-esterase inhibitor, IV) —

Getting Berinert (C1-Esterase Inhibitor) Covered by Aetna CVS Health in Texas: Complete Prior Authorization Guide

Answer Box: Quick Path to Approval

To get Berinert (C1-esterase inhibitor, IV) covered by Aetna CVS Health in Texas, you need prior authorization with documented HAE diagnosis, failed alternative treatments, and specialist prescription. Submit the Aetna Berinert precertification form electronically via Availity or fax to 1-866-249-6155. Include lab results showing C1-INH deficiency, prior therapy failures, and attack frequency documentation. If denied, you have 180 days to appeal internally, then request external review through Texas Department of Insurance. Start by verifying your specific Aetna plan and gathering HAE documentation today.

Table of Contents

  1. Verify Your Plan and Coverage
  2. Required Forms and Documentation
  3. Submission Methods: Portal, Fax, and Mail
  4. CVS Specialty Pharmacy Enrollment
  5. Appeals Process for Texas
  6. Common Denial Reasons and Solutions
  7. Support Resources and Contact Numbers
  8. Cost Assistance Programs
  9. Frequently Asked Questions

Verify Your Plan and Coverage

Before submitting any prior authorization request, confirm your specific Aetna plan details. Aetna CVS Health operates different formularies and coverage policies depending on whether you have commercial insurance, Medicare Advantage, or Medicaid (Aetna Better Health of Texas).

What to check first:

  • Your member ID and plan type (found on your insurance card)
  • Whether Berinert requires prior authorization on your specific formulary
  • Your current formulary tier for Berinert
  • Any step therapy requirements
Tip: Call Aetna member services at the number on your insurance card to verify these details before your doctor submits the prior authorization.

Coverage Requirements at a Glance:

Requirement What It Means Where to Find It
Prior Authorization Required for all Aetna plans Aetna 2024 Precertification List
HAE Diagnosis Lab-confirmed C1-INH deficiency Aetna HAE Policy
Specialist Prescription Immunologist, allergist, or hematologist Aetna clinical criteria
Step Therapy May require trial of alternatives first Plan-specific formulary
Quantity Limits Per attack dosing restrictions Prior auth determination

Required Forms and Documentation

Primary Form: Aetna Berinert Precertification Request

Download the current Aetna Berinert precertification form. As of 2024, all prior authorization requests must be submitted electronically through Availity or other approved portals.

Essential Clinical Documentation

Your healthcare provider must include:

  1. HAE Diagnosis Confirmation
    • C1-INH antigenic level below normal range
    • OR normal C1-INH with functional level <50% of normal
    • OR genetic testing results for HAE with normal C1-INH
  2. Attack History and Severity
    • Frequency of HAE attacks over past 6-12 months
    • Emergency department visits for HAE attacks
    • Response to previous treatments
  3. Prior Therapy Documentation
    • Trials and failures of other HAE treatments
    • Contraindications to alternative therapies
    • Reasons why Berinert is medically necessary
  4. Dosing and Administration Plan
    • Weight-based dosing (20 IU/kg per attack)
    • Site of care (hospital, infusion center, home)
    • Training plan for self-administration if applicable
Clinician Corner: Medical necessity letters should reference the FDA-approved indication for acute HAE attacks and include specific C1-INH lab values with reference ranges from your laboratory.

Submission Methods: Portal, Fax, and Mail

Electronic Submission (Preferred)

Availity Portal: www.availity.com

  • Fastest processing time (typically 2-3 business days)
  • Real-time status updates
  • Secure document upload for supporting materials

Fax Submission

Commercial Plans: 1-866-249-6155 Aetna Better Health (Medicaid): 1-866-706-0529

Include a cover sheet with:

  • Patient name and Aetna member ID
  • Provider name and NPI number
  • "URGENT - HAE MEDICATION PRIOR AUTH" if expedited review needed
  • Complete page count

Phone Support for Providers

Provider Services: 1-855-240-0535 (Monday-Friday, 8 AM-6 PM Central)

  • Use for urgent cases or submission questions
  • Have patient member ID and provider NPI ready

CVS Specialty Pharmacy Enrollment

Once Berinert is approved, you'll likely need to use CVS Specialty Pharmacy for dispensing and administration coordination.

Enrollment Steps

  1. Complete CVS Specialty Enrollment Form
    • Download the HAE-specific enrollment form
    • Provide insurance information and prescription details
    • Both patient and prescriber signatures required
  2. Submit to CVS Specialty
    • Fax: 1-800-323-2445
    • Phone: Contact number on enrollment form
    • Online: Through CVS Specialty provider portal
  3. Patient Portal Access
    • Register at CVS Specialty website after first prescription transfer
    • Email address serves as User ID
    • Two-step verification required for health information access

Berinert Connect Support Program

Consider enrolling in Berinert Connect for additional case management and patient support services. Call 1-877-236-4423 for enrollment information.

Appeals Process for Texas

If your initial prior authorization is denied, Texas law provides strong appeal rights with specific timelines.

Internal Appeal (First Level)

Timeline: File within 180 days of denial Decision: Aetna must respond within 30 days (pre-service) or 60 days (post-service) Expedited: 72 hours for urgent cases

How to File:

  • Use denial letter instructions and appeal form
  • Include additional medical documentation
  • Request peer-to-peer review with HAE specialist

External Review (Independent Review Organization)

When Available: After internal appeal denial or for urgent cases Timeline: File within 4 months of final internal denial Decision: 20 days standard, 5 days for urgent cases Cost: Paid by Aetna (no cost to you)

Texas Department of Insurance IRO Contacts:

  • IRO Information Line: 1-888-834-2476
  • Managed Care Quality Assurance: 1-866-554-4926
  • Consumer Help: 1-800-252-3439
Note: The IRO decision is binding on Aetna. If they overturn the denial, Aetna must provide coverage.

Expedited Appeals for Urgent Cases

For life-threatening situations or if you're already receiving Berinert, you can request expedited external review immediately without completing internal appeals first.

Common Denial Reasons and Solutions

Denial Reason How to Overturn Documentation Needed
"Not medically necessary" Provide attack frequency, ER visits, specialist letter HAE attack logs, ER records, medical necessity letter
"Step therapy required" Document failures/contraindications to alternatives Prior therapy records, adverse reaction notes
"Experimental/investigational" Reference FDA approval for HAE attacks FDA label, clinical guidelines
"Quantity limits exceeded" Justify dosing based on weight and attack severity Weight-based dosing calculation, attack severity documentation
"Site of care restriction" Provide medical justification for requested location Clinical rationale for home vs. facility administration

From Our Advocates

A composite tip from coverage specialists: "We've seen HAE denials overturned most successfully when families include a detailed attack diary showing emergency visits, work/school days missed, and quality of life impact. Combine this with clear lab values and specialist letters referencing published HAE management guidelines. The key is painting a complete picture of medical necessity beyond just the diagnosis."

Support Resources and Contact Numbers

Aetna Member Services

  • Commercial Plans: Number on your insurance card
  • Aetna Better Health (Texas Medicaid): Contact information

Texas Insurance Assistance

  • Texas Department of Insurance: 1-800-252-3439
  • Office of Public Insurance Counsel: 1-877-611-6742
  • TDI IRO Information: 1-888-834-2476

Clinical Support

  • Berinert Connect: 1-877-236-4423
  • CSL Behring Medical Information: Contact through official website

Advocacy Organizations

  • Disability Rights Texas: For Medicaid appeals and fair hearings
  • US HAEA (Hereditary Angioedema Association): Patient advocacy and resources

Cost Assistance Programs

Manufacturer Support

Berinert Connect offers financial assistance programs for eligible patients. Income and insurance requirements apply.

Copay Assistance

Check for current copay card programs through CSL Behring's website or by calling Berinert Connect.

Foundation Grants

  • Patient Access Network (PAN) Foundation
  • HealthWell Foundation
  • Good Days Foundation
Important: Apply for assistance programs early in your treatment journey, as funding may be limited.

Frequently Asked Questions

How long does Aetna prior authorization take in Texas? Standard review takes 30 days for pre-service requests. Expedited review for urgent cases must be completed within 72 hours.

What if Berinert isn't on my formulary? You can request a formulary exception with medical necessity documentation. The process follows the same prior authorization pathway.

Can I appeal if I move to Texas from another state? Yes, but you'll need to resubmit prior authorization under Texas Aetna policies. Previous approvals don't automatically transfer.

Does step therapy apply if I've failed alternatives outside Texas? Prior therapy failures from other states should be accepted with proper documentation. Include medical records showing specific treatments tried and outcomes.

What's the difference between precertification and prior authorization? Aetna uses these terms interchangeably. Both refer to the requirement to get approval before coverage begins.

Can I request a peer-to-peer review? Yes, your doctor can request to speak directly with an Aetna medical director during the review process.

What if my doctor isn't an HAE specialist? Aetna requires prescription by or in consultation with an immunologist, allergist, or hematologist familiar with HAE treatment.

How do I know if my appeal was successful? You'll receive written notification from Aetna. For external reviews, Texas Department of Insurance also provides notification.

Getting personalized help with your Berinert coverage: Counterforce Health specializes in turning insurance denials into successful appeals by analyzing your specific denial reasons and crafting evidence-based responses that align with payer policies. Their platform helps patients and providers navigate complex prior authorization requirements and appeal processes more effectively.

For additional support with your Aetna coverage challenges, Counterforce Health's team can help identify the specific documentation needed for your case and draft targeted appeal letters that address Aetna's clinical criteria for Berinert coverage.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and is not medical advice. Always consult with your healthcare provider about your specific medical condition and treatment options. Insurance coverage policies change frequently—verify current requirements with Aetna and review your specific plan documents. For official appeals guidance in Texas, contact the Texas Department of Insurance.

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