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

How to Get Berinert (C1-Esterase Inhibitor) Covered by Aetna CVS Health in Florida: Complete PA Guide with Forms and Appeals

Answer Box: Fast Track to Berinert Coverage with Aetna CVS Health in Florida

Aetna CVS Health requires prior authorization for Berinert (C1-esterase inhibitor) in Florida. Your fastest path: Have your HAE specialist submit a PA request via the Aetna provider portal with confirmed HAE diagnosis, documented Ruconest failure/contraindication, and clinical notes showing acute attack patterns. Start today: Call Aetna Specialty Pharmacy at 1-855-240-0535 to verify your plan's requirements and get the correct forms.

Table of Contents

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Berinert prescriptions 2025 Aetna Precert List Aetna
Step Therapy Must try Ruconest first (unless contraindicated) Aetna Medical Policy 0782 Aetna
Specialist Requirement HAE specialist prescription required Aetna Medical Policy 0782 Aetna
Diagnosis Code ICD-10 for hereditary angioedema Provider documentation CMS
Appeal Deadline 180 days from denial notice Florida Insurance Code FL DFS

Verify Your Plan and Find the Right Forms

Before starting your prior authorization, confirm your specific Aetna plan type. CVS Caremark manages most Aetna specialty medications, but requirements vary between commercial, Medicare Advantage, and Medicaid plans.

Step 1: Check Your Member Portal Log into your Aetna member portal and verify:

  • Your formulary tier for Berinert (likely Tier 4/5 specialty)
  • Whether CVS Specialty is your designated pharmacy
  • Any quantity limits or site-of-care restrictions

Step 2: Confirm Plan Type

  • Commercial plans: Use standard Aetna PA forms
  • Medicare Advantage: Different phone number (1-866-503-0857)
  • Florida Medicaid: May have state-specific requirements
Tip: If you're unsure about your plan type, the member ID format often indicates it—call member services at the number on your card for confirmation.

Prior Authorization Forms and Requirements

Required Documentation Checklist

For Your Doctor to Submit:

  • Aetna Specialty Medication Request Form
  • Confirmed HAE diagnosis with lab results:
    • C1-INH antigenic level below normal, OR
    • Normal antigenic level with functional C1-INH <50%, OR
    • HAE with normal C1-INH (genetic mutations documented)
  • Documentation of Ruconest trial failure, contraindication, or intolerance
  • Clinical notes showing acute attack patterns
  • Prescription for 20 IU/kg IV dosing (per FDA labeling)

Step Therapy Requirements

Aetna requires a Ruconest trial first unless you have documented:

  • Allergic reaction or contraindication to recombinant C1-INH
  • Treatment failure after one month of appropriate dosing
  • Medical urgency requiring immediate Berinert access

Document these exceptions clearly in your PA submission to avoid automatic denials.

Submission Portals and Electronic Options

Primary Submission Method: Availity Portal

Most providers use Availity for electronic PA submissions to Aetna. This portal offers:

  • Real-time eligibility verification
  • Electronic prior authorization (ePA) through Surescripts
  • Faster processing (often <6 seconds for routine approvals)
  • Automatic status updates

Provider Setup Required: Your doctor's office needs an Availity account with Aetna credentialing.

Alternative Electronic Options

CoverMyMeds Integration Many practices use CoverMyMeds for streamlined PA submissions. The platform connects directly to Aetna's systems and can auto-populate patient information.

CVS Specialty Portal For specialty pharmacy enrollment, providers can access forms at CVS Specialty Provider Portal.

Fax Numbers and Mail Addresses

Aetna Specialty Drug Prior Authorization

Primary Fax: 1-877-269-9916 (TTY: 711) Phone Support: 1-855-240-0535 (TTY: 711)

For Medicare Advantage Plans: Phone: 1-866-503-0857

Mailing Address for Written Appeals

Aetna Prior Authorization
1300 E. Campbell Rd.
Richardson, TX 75081
Important: Always include a cover sheet with member ID, drug name (Berinert), and prescriber NPI when faxing. Keep fax confirmation receipts for your records.

Specialty Pharmacy Enrollment

CVS Specialty Enrollment Process

Step 1: Provider Completes HAE Enrollment Form Download the CVS Specialty Hereditary Angioedema Enrollment Form and include:

  • Patient demographics and insurance information
  • Prescriber details with NPI and signature
  • Complete prescription with dosing instructions

Step 2: Patient Consent and Support Programs Consider enrolling in BERINERT ConnectSM for:

  • Financial assistance programs
  • Copay support (if eligible)
  • Patient education resources
  • 24/7 support at 1-877-236-4423

Processing Timeline: Allow 10-12 weeks for pharmacy enrollment if your provider isn't already credentialed with CVS Specialty.

Support Phone Lines and Contacts

Member Support

Aetna Member Services: Number on your ID card CVS Caremark: 1-800-552-8159 for formulary questions

Provider Support

Aetna Precertification: 1-855-240-0535 CVS Specialty Support: Available through provider portal

What to Ask When You Call:

  • "Is Berinert on my plan's formulary?"
  • "What tier is it, and what's my copay?"
  • "Do I need to use CVS Specialty pharmacy?"
  • "What's the status of my pending PA request?"
  • "Can I get an expedited review for urgent needs?"

For Healthcare Providers working with Counterforce Health, our platform can automatically track these requirements and generate targeted appeals when denials occur, saving significant time in the prior authorization process.

Florida Insurance Appeals and External Review

Internal Appeal Process

Timeline: You have 180 days from denial notice to file an internal appeal with Aetna.

How to Submit:

  1. Write a formal appeal letter citing your policy number and the denial
  2. Include additional clinical evidence supporting medical necessity
  3. Request peer-to-peer review with an HAE specialist
  4. Submit via certified mail or secure provider portal

Aetna's Response Time: 30 days for standard appeals, 72 hours for urgent cases

Florida External Review

If Aetna denies your internal appeal, Florida law provides an independent external review process.

Contact Florida Department of Financial Services:

Timeline: You have 4 months after final internal denial to request external review.

What Happens: An independent medical reviewer (not affiliated with Aetna) evaluates whether the denial was appropriate based on medical necessity and your plan's coverage criteria.

Cost: Free to consumers in Florida

Note: The external reviewer's decision is binding on Aetna if they overturn the denial.

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Submit attack logs and specialist letter HAE diagnosis confirmation, attack frequency/severity
"Step therapy not met" Document Ruconest failure/contraindication Trial records, adverse reaction notes
"Experimental/investigational" Cite FDA approval for acute HAE FDA labeling for on-label use
"Quantity limits exceeded" Justify weight-based dosing BMI calculation, 20 IU/kg dosing rationale
"Site of care restriction" Document need for home/office administration Emergency access plan, caregiver training

Clinician Corner: Medical Necessity Letter Essentials

Include These Elements:

  • HAE diagnosis with specific lab values and dates
  • Documentation of acute attack patterns (frequency, severity, location)
  • Prior treatment history with other HAE medications
  • Clinical rationale for Berinert vs. alternatives
  • Weight-based dosing calculation (20 IU/kg)
  • Monitoring plan and emergency protocols

Key Clinical References:

When to Update Your Resources

Quarterly Reviews (Every 3 Months):

Annual Reviews:

  • Confirm your plan's formulary status for Berinert
  • Update contact information and fax numbers
  • Review Florida insurance regulations for any changes

When to Check Immediately:

  • After any plan changes or renewals
  • If you receive unexpected denials
  • Before starting a new prescription
From our advocates: We've seen cases where patients successfully appealed denials by documenting specific attack triggers and demonstrating that Berinert's rapid onset was medically necessary for their lifestyle (such as a teacher who couldn't risk prolonged attacks during the school day). While outcomes vary, thorough documentation of your individual medical needs often strengthens appeals significantly.

Frequently Asked Questions

Q: How long does Aetna's prior authorization process take in Florida? A: Standard PA decisions typically take 30-45 days. Urgent requests can be expedited to 72 hours if you demonstrate immediate medical need.

Q: What if Berinert isn't on my Aetna formulary? A: You can request a formulary exception by documenting medical necessity and failure of formulary alternatives. Your doctor must show that covered options are inadequate for your condition.

Q: Can I appeal if I've been stable on Berinert from another state? A: Yes. Document your treatment history and clinical stability. Florida insurers must consider out-of-state medical records as valid evidence for appeals.

Q: Does Aetna cover Berinert for prophylaxis? A: Generally no. Aetna's medical policy covers Berinert only for acute attacks and short-term pre-procedural prophylaxis.

Q: What should I do if CVS Specialty can't fill my prescription? A: Contact Aetna member services to confirm your specialty pharmacy options. Some plans allow alternative specialty pharmacies with prior approval.

Organizations like Counterforce Health specialize in turning complex insurance denials into successful appeals by analyzing payer policies and crafting evidence-based rebuttals that address specific denial reasons.

Sources & Further Reading

Disclaimer: This information is for educational purposes and doesn't constitute medical advice. Coverage decisions depend on your specific plan and medical circumstances. Always consult your healthcare provider and insurance plan documents for the most current requirements. For additional help with insurance appeals in Florida, contact the Florida Department of Financial Services at 1-877-693-5236.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.