By Counterforce Health Team in Arikayce (amikacin liposome inhalation) —

How to Get Arikayce (Amikacin Liposome Inhalation) Covered by Aetna CVS Health in Washington: Prior Authorization Forms, Appeals, and Timelines

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

Arikayce (amikacin liposome inhalation) requires prior authorization from Aetna CVS Health for refractory MAC lung disease. You need 6+ months of failed multidrug therapy, positive MAC cultures, and specialist involvement. Submit via Availity portal with medical necessity letter, culture results, and treatment history. Standard decisions take 30-45 days; expedited reviews 72 hours. If denied, appeal within 180 days and request external review through Washington's IRO process.

Start today: Verify coverage, gather culture/imaging records, and have your pulmonologist compile the prior authorization request.

Table of Contents

Coverage Requirements at a Glance

Requirement Details Documentation Needed Source
Prior Authorization Required for all plans PA form via Availity portal Aetna Precert List
Diagnosis Refractory MAC lung disease (A31.0) Positive cultures, chest CT/imaging Aetna Policy 3150-A
Step Therapy 6+ months failed standard therapy Treatment records with dates/outcomes Aetna Policy 3150-A
Prescriber Pulmonologist or ID specialist only Credentials verification Aetna Policy 3150-A
Combination Therapy Must be part of multidrug regimen Current medication list FDA Label Requirements
Appeals Deadline 180 days from denial Written appeal submission Washington State Law

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage (Patient/Clinic)
    • Check member portal or call Aetna member services
    • Confirm specialty pharmacy benefits through CVS Caremark
    • Timeline: Same day
  2. Gather Clinical Documentation (Clinic)
    • Recent positive MAC cultures (within 6 months)
    • Chest CT showing nodular bronchiectasis or fibrocavitary disease
    • Complete treatment history with specific dates and outcomes
    • Timeline: 1-3 days
  3. Compile Medical Necessity Letter (Prescriber)
  4. Submit Prior Authorization (Clinic)
    • Use Availity portal (fastest)
    • Alternative: Fax 1-866-249-6155 or call 1-866-814-5506
    • Timeline: Same day submission
  5. Track Decision (Clinic/Patient)
    • Standard review: 30-45 days
    • Expedited review: 72 hours (if urgent)
    • Follow up via portal or phone
  6. Appeal if Denied (Patient/Clinic)
    • Submit within 180 days to Aetna
    • Include new evidence or peer-to-peer review request
    • Timeline: 30 days for internal appeal decision
  7. Request External Review (Patient)
    • File with Washington IRO within 60 days of final denial
    • Use Coverage Rights template (page 29)
    • Timeline: 20-45 days for binding decision

Prior Authorization Forms and Submission

Electronic Submission (Preferred)

  • Availity Portal: Primary method for fastest processing (3-5 business days)
  • Novologix: Alternative specialty drug portal
  • Provider EMR Integration: Some systems connect directly

Fax and Phone Options

  • Specialty PA Fax: 1-866-249-6155
  • General PA Fax: 1-888-836-0730
  • Phone: 1-866-814-5506
  • Mailing Address: Medical Exception Unit, 1300 East Campbell Rd, Richardson, TX 75081
Tip: Electronic submission through Availity typically processes faster than fax or mail. Create an account at the Aetna provider portal if you haven't already.

Medical Necessity Letter Checklist

Your prescriber's medical necessity letter should include:

Patient Information

  • Full name, date of birth, member ID
  • Diagnosis: Refractory MAC lung disease (ICD-10: A31.0)
  • Current symptoms and functional impact

Clinical Evidence

  • Positive sputum culture results with species identification
  • Chest imaging findings (CT preferred)
  • Pulmonary function tests if available

Treatment History

  • Specific medications tried with exact dates and durations
  • Reasons for discontinuation (failure vs. intolerance)
  • Documentation of at least 6 consecutive months of guideline-based therapy

Current Plan

  • Arikayce dosing: 590 mg once daily via nebulization
  • Continuing background multidrug regimen
  • Monitoring plan for hearing and kidney function
  • Treatment goals and expected duration

Guideline References

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
Insufficient treatment duration Provide pharmacy records showing 6+ months Prescription fill history, clinic notes
Not refractory disease Submit recent positive cultures despite therapy Lab results with dates, treatment timeline
Missing specialist Confirm pulmonologist or ID physician prescribing Provider credentials, NPI verification
Lack of combination therapy Document current multidrug regimen Current medication list, prescriptions
Experimental/investigational Cite FDA approval and guidelines FDA label, ATS/ERS guidelines
Step therapy not met Document failures of standard MAC therapy Treatment records, intolerance notes
Note: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and plan policies to create point-by-point rebuttals aligned with payer requirements.

Appeals Process in Washington

Internal Appeals (First Level)

  • Deadline: 180 days from denial notice
  • Method: Written request to Aetna with new evidence
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Required: Member ID, denial letter, additional documentation

External Review (Independent Review Organization)

Washington provides strong consumer protections through its external review process:

  • Eligibility: After exhausting internal appeals or receiving final denial
  • Deadline: 60 days from final internal denial
  • Process: Submit written request to Aetna, who assigns certified IRO
  • Timeline: 20 days (fully-insured plans) or 45 days (self-insured plans)
  • Decision: Binding on Aetna if overturned

External Review Request Steps:

  1. Download sample letter template from Coverage Rights (page 29)
  2. Include denial letters, medical records, and new evidence
  3. Submit to Aetna within 60 days
  4. Provide additional information to assigned IRO (5 business days allowed)

Washington State Resources

  • Insurance Commissioner Consumer Line: 1-800-562-6900
  • Online Complaint Portal: Available on OIC website
  • IRO Performance Reports: Published by Washington Insurance Commissioner

For self-insured employer plans, federal ERISA rules may apply instead of state law. Contact the U.S. Department of Labor for ERISA plan appeals.

Costs and Patient Support

Manufacturer Support Programs

  • Arikayce Patient Support Program: Financial assistance and co-pay support
  • Eligibility: Income-based qualification, insurance requirements vary
  • Contact: Arikayce patient resources

Foundation Grants

  • Patient Advocate Foundation: Co-pay relief for qualifying patients
  • Good Days: Financial assistance for chronic disease medications
  • Healthwell Foundation: Grants for specific conditions and medications

State Programs

  • Washington Apple Health (Medicaid): Coverage for eligible low-income residents
  • Washington Prescription Drug Program: State-sponsored assistance options
From our advocates: "We've seen Washington patients successfully overturn initial Arikayce denials by working closely with their pulmonologist to document the full 6-month treatment history and submit comprehensive culture results. The key is often providing pharmacy records that clearly show adherence to the previous regimen despite persistent positive cultures."

When to Escalate to State Regulators

Contact the Washington Office of the Insurance Commissioner if:

  • Aetna fails to provide required appeal information
  • Internal appeal deadlines are not met
  • External review process is improperly handled
  • You suspect bad faith denial practices

Washington OIC Contact Information:

  • Consumer Advocacy: 1-800-562-6900
  • Online: File complaint through OIC website
  • Services: Appeal assistance, template letters, IRO oversight

The OIC actively monitors insurer performance and can intervene in cases of procedural violations or pattern denials.

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take for Arikayce in Washington? Standard reviews take 30-45 days, while expedited reviews for urgent cases are completed within 72 hours. Electronic submission through Availity typically processes faster than fax or mail.

What if Arikayce is non-formulary on my Aetna plan? Request a formulary exception along with your prior authorization. Provide medical necessity documentation showing why preferred alternatives are inappropriate or have failed.

Can I request an expedited appeal if my condition is worsening? Yes, if your health could be seriously jeopardized by delays, request expedited review. Both internal appeals and external reviews have expedited options (72 hours for internal, expedited IRO review available).

Does step therapy apply if I failed MAC treatment outside Washington? Treatment failures from other states count toward step therapy requirements. Provide complete medical records and pharmacy documentation from all treating facilities.

What happens if the external IRO overturns Aetna's denial? The decision is binding on Aetna, and they must provide coverage according to the IRO's determination. This is enforceable under Washington state law.

How do I transfer Arikayce prescription to CVS Specialty Pharmacy? Your prescriber sends the prescription directly to CVS Specialty once prior authorization is approved. CVS will contact you to coordinate delivery and administration training.

Can I appeal if my employer plan is self-insured? Self-insured plans may follow federal ERISA rules instead of Washington state law. Contact your plan administrator and potentially the U.S. Department of Labor for guidance on appeal rights.

What if I need help navigating the appeals process? Counterforce Health helps patients and clinicians turn insurance denials into successful appeals by creating evidence-backed rebuttals tailored to specific payer policies and requirements.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. Consult with your healthcare provider and insurance plan for specific guidance. For personalized assistance with insurance appeals, contact the Washington Office of the Insurance Commissioner at 1-800-562-6900.

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