By Counterforce Health Team in Acthar Gel (repository corticotropin injection) —

How to Get Acthar Gel Covered by Aetna CVS Health in Washington: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Acthar Gel Approved by Aetna CVS Health in Washington

Aetna CVS Health requires prior authorization for all Acthar Gel (repository corticotropin injection) uses in Washington. The fastest path to approval: (1) Submit a complete Statement of Medical Necessity documenting failed corticosteroid therapy, (2) Call Aetna Specialty Pharmacy at 866-752-7021 for urgent cases, (3) If denied, file an internal appeal within 180 days, then request Washington's external review through the Office of the Insurance Commissioner within 180 days of final denial. Success depends on meeting strict medical necessity criteria—primarily infantile spasms in children under 2 or MS exacerbations after steroid failure.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Medical Necessity Criteria
  4. Timing and Deadlines
  5. Common Denial Reasons and Solutions
  6. Appeals Process in Washington
  7. Cost and Financial Assistance
  8. Specialty Pharmacy Requirements
  9. FAQ: Most Common Questions
  10. When to Escalate

Coverage Basics

Is Acthar Gel Covered by Aetna CVS Health?

Yes, but with strict limitations. Acthar Gel is covered on Aetna's specialty drug formulary as a Tier 4 or 5 non-preferred specialty medication, requiring prior authorization for all uses. Coverage is typically limited to:

  • Infantile spasms in children under 24 months
  • Acute MS exacerbations after corticosteroid failure or contraindication
  • Select FDA-labeled conditions with exceptional justification
Note: Most rheumatologic, dermatologic, and other FDA-labeled uses are frequently denied as "not medically necessary" due to insufficient evidence compared to standard corticosteroids.

Which Aetna Plans Apply?

This guidance applies to Washington residents with:

  • Aetna commercial plans (HMO, PPO, EPO)
  • Aetna Medicare Advantage plans
  • Aetna Medicaid managed care plans

Self-funded employer plans may follow different rules but often use similar processes.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Gather Required Documentation (Patient/Provider)
    • Complete medical records showing diagnosis
    • Detailed history of all prior corticosteroid trials
    • Lab results, imaging, specialist notes
    • Timeline: Allow 2-3 days for record compilation
  2. Complete Statement of Medical Necessity (Provider)
  3. Submit Prior Authorization (Provider)
    • Phone: 866-752-7021 (Aetna Specialty Pharmacy)
    • Fax: 888-267-3277
    • For urgent cases, call first then follow with fax
    • Timeline: Submit within 1 business day of completion
  4. Track Decision (Provider/Patient)
    • Standard decisions: 14 business days
    • Expedited decisions: 72 hours
    • Check status via Aetna provider portal or member services

Required Documentation Checklist

  • Confirmed diagnosis with supporting tests
  • Complete list of failed corticosteroids (drug, dose, duration, outcome)
  • Contraindications or intolerance to alternatives
  • Specialist consultation notes (neurologist for MS, pediatric neurologist for infantile spasms)
  • Proposed treatment plan with monitoring protocols
  • Medical necessity letter addressing Aetna's specific criteria

Medical Necessity Criteria

Aetna's Approved Indications

Condition Age/Requirements Step Therapy Success Likelihood
Infantile Spasms Under 24 months, confirmed West syndrome May be bypassed High
MS Exacerbations Adults, acute relapse with functional impairment Failed high-dose steroids Moderate
Rheumatologic Various autoimmune conditions Failed steroids + DMARDs Low
Other FDA-labeled Per label indications Extensive prior therapy Very Low

Clinician Corner: Medical Necessity Letter

Your letter should address these key points for maximum approval chances:

For Infantile Spasms:

  • EEG findings consistent with hypsarrhythmia
  • Age verification (must be under 24 months)
  • Seizure frequency and developmental impact
  • Why ACTH/Acthar is preferred over vigabatrin or steroids

For MS Exacerbations:

  • EDSS score changes and functional impact
  • Specific corticosteroids tried (methylprednisolone dose/duration)
  • Contraindications to steroids (diabetes, psychiatric history, etc.)
  • Timeline of relapse and urgency of treatment

Include citations from:

  • FDA prescribing information
  • Relevant specialty society guidelines
  • Peer-reviewed literature supporting use in your patient's specific situation

Timing and Deadlines

Prior Authorization Timeline

Process Step Standard Expedited Notes
Submission to Decision 14 business days 72 hours Call for urgent cases
Provider Appeal Filing Within 180 days Same From initial denial
Provider Appeal Decision 45 business days 72 hours May request peer-to-peer
Member Appeal Filing Within 60-180 days Same Check plan documents
External Review Filing Within 180 days Same After final internal denial

When to Request Expedited Review

Request expedited review when delay could:

  • Worsen seizures in infantile spasms
  • Prolong MS relapse with permanent disability risk
  • Cause serious jeopardy to health or function

Have your prescriber document the urgency in writing and submit with the expedited request.

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Appeal with peer-to-peer review Detailed failure history, specialist letter
"Experimental/investigational" Cite FDA labeling and guidelines FDA PI, society recommendations
"Step therapy not met" Document all prior therapies Pharmacy records, provider notes
"Non-formulary" Request formulary exception Medical necessity justification
"Quantity limits exceeded" Show clinical rationale for dosing Weight-based calculations, literature

Most Effective Appeal Strategies

  1. Request peer-to-peer review - Have your specialist speak directly with Aetna's medical director
  2. Submit comprehensive documentation - Include all prior therapy records, not just summaries
  3. Use clinical language - Focus on medical necessity, not cost or convenience
  4. Cite specific policy sections - Reference Aetna's own coverage criteria

Appeals Process in Washington

Washington residents have strong appeal rights through both Aetna's internal process and the state's external review system.

Internal Appeals (Through Aetna)

Level 1: Provider Appeal

  • File within 180 days of denial
  • Use Aetna's Provider Appeal Form
  • Decision within 45 business days
  • Can request peer-to-peer physician consultation

Level 2: Member Appeal

  • File within 60-180 days (check your plan)
  • Available after provider appeal or directly
  • Decision within 30 days standard, 72 hours expedited

External Review (Washington State)

After exhausting internal appeals, Washington residents can request independent external review through the Office of the Insurance Commissioner (OIC).

How It Works:

  • File within 180 days of final internal denial
  • OIC assigns an independent review organization (IRO)
  • Board-certified specialist reviews your case
  • Decision is binding on Aetna
  • No cost to you

Contact Information:

Timeline:

  • Standard review: 30 days
  • Expedited review: 72 hours (for urgent cases)
From Our Advocates: We've seen several Washington patients successfully overturn Acthar denials through external review, particularly for infantile spasms and MS cases where internal appeals focused too narrowly on cost rather than medical necessity. The key was providing comprehensive documentation of failed alternatives and clear evidence of functional impairment.

Cost and Financial Assistance

Typical Out-of-Pocket Costs

  • Specialty tier coinsurance: 25-50% of drug cost
  • Monthly copay cap: $150-$500 (varies by plan)
  • Annual out-of-pocket maximum: $8,700-$9,450 (2025 limits)

Financial Assistance Options

Mallinckrodt Acthar Patient Support Program

  • Up to $15,000 per year in copay assistance
  • Reduces costs to $0-$50 per month for eligible patients
  • Commercial insurance only (not Medicare/Medicaid)
  • Call: 1-888-435-2284

For Medicare/Medicaid Patients:

  • Patient assistance foundations (PAN Foundation, HealthWell)
  • State pharmaceutical assistance programs
  • Hospital charity care programs

Counterforce Health helps patients navigate these complex financial assistance programs while simultaneously working on appeals to get the medication covered by insurance, reducing the long-term financial burden.

Specialty Pharmacy Requirements

Acthar Gel must be dispensed through CVS Specialty Pharmacy or another Aetna-contracted specialty pharmacy.

What to Expect

  1. Benefits Investigation - CVS Specialty will verify coverage and costs
  2. Clinical Consultation - Pharmacist will review administration and side effects
  3. Delivery Coordination - Medication shipped to your home or clinic
  4. Ongoing Support - Refill reminders and clinical monitoring

Important Notes

  • Cannot use retail pharmacies
  • Prior authorization must be approved before dispensing
  • Cold chain shipping required (refrigerated medication)
  • Injection training may be provided

FAQ: Most Common Questions

Q: How long does Aetna prior authorization take for Acthar Gel in Washington? A: Standard decisions take up to 14 business days. Expedited reviews are completed within 72 hours when medical urgency is documented.

Q: Can I get Acthar Gel covered for rheumatoid arthritis? A: Unlikely. While FDA-approved for RA, Aetna typically denies these requests as "not medically necessary" compared to standard DMARDs and biologics. Success requires extensive documentation of failed therapies.

Q: What if my child needs Acthar Gel for infantile spasms? A: This has the highest approval rate. Ensure documentation includes confirmed diagnosis, EEG findings, age verification (under 24 months), and pediatric neurologist consultation.

Q: Does Washington have any special protections for specialty drug appeals? A: Yes. Washington's external review process is particularly strong, with independent medical experts and binding decisions. The Office of the Insurance Commissioner actively assists consumers with appeals.

Q: Can I request an expedited appeal if my MS is relapsing? A: Yes. Have your neurologist document that delay would cause serious jeopardy to your health or ability to regain function. Both internal and external appeals can be expedited.

Q: What happens if I'm already taking Acthar Gel and Aetna denies reauthorization? A: File an expedited appeal immediately, as interrupting treatment could be dangerous. Your doctor should request continuation of therapy pending appeal resolution.

Q: Are there alternatives to Acthar Gel that might be more easily covered? A: For most conditions, yes. High-dose corticosteroids (methylprednisolone, prednisone) are preferred first-line treatments. For infantile spasms, vigabatrin may be an alternative depending on etiology.

Q: How do I know if my Aetna plan is subject to Washington state external review? A: Fully-insured individual and small group plans are subject to Washington law. Self-funded employer plans (ERISA) may have different processes but often provide similar external review options.

When to Escalate

Contact Washington Regulators

If you encounter problems with Aetna's appeal process:

Washington Office of the Insurance Commissioner

  • Phone: 1-800-562-6900
  • Website: insurance.wa.gov
  • File complaint online for process violations or unreasonable delays

Red Flags Requiring Escalation

  • Appeals denied without medical review
  • Deadlines not met by Aetna
  • Lack of response to expedited requests
  • Denial of external review rights

The innovative approach used by Counterforce Health combines clinical expertise with regulatory knowledge to identify these procedural violations and ensure patients receive fair consideration of their appeals.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and procedures may change. Always verify current requirements with your insurance plan and consult healthcare providers for medical decisions. For personalized assistance with insurance appeals and prior authorizations, contact the Washington Office of the Insurance Commissioner or qualified patient advocacy services.

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