By Counterforce Health Team in Besponsa (inotuzumab ozogamicin) —

How to Get Besponsa (Inotuzumab Ozogamicin) Covered by Aetna CVS Health in Pennsylvania: Complete Guide with Forms and Appeal Process

Quick Answer: Getting Besponsa Covered in Pennsylvania

Besponsa (inotuzumab ozogamicin) requires prior authorization from Aetna CVS Health for CD22-positive B-cell ALL. In Pennsylvania, you have strong appeal rights—about 50% of external reviews overturn denials. Start today: 1) Verify your plan covers specialty drugs, 2) Have your oncologist submit the Besponsa precertification form to fax 1-888-267-3277, 3) If denied, you have 180 days for internal appeals plus 4 months for Pennsylvania's independent external review. CVS Specialty Pharmacy handles fulfillment at 1-800-237-2767.

Table of Contents

Start Here: Verify Your Plan and Find the Right Forms

Before diving into paperwork, confirm your specific Aetna plan details. Not all Aetna plans are identical—some are commercial employer plans, others are Medicare Advantage, and Pennsylvania also has Aetna Better Health Medicaid plans.

Step 1: Check Your Member ID Card

  • Look for "CVS Health" or "Caremark" logos—this confirms specialty drug coverage
  • Note your member ID number and group number
  • Verify if you have medical and pharmacy benefits through the same plan

Step 2: Confirm Besponsa Coverage Status Besponsa appears on Aetna's 2025 precertification list, meaning prior authorization is required regardless of your specific plan tier.

Note: Even if Besponsa requires PA, this doesn't mean it's excluded from coverage—it means Aetna needs clinical documentation to approve it.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Must be approved before treatment 2025 Precert List Aetna
CD22+ B-cell ALL Diagnosis must match FDA indication Medical Policy 0919 Aetna
Relapsed/Refractory Must have failed prior therapies Medical Policy & FDA Label Aetna/FDA
Specialty Pharmacy Must use CVS Specialty for fulfillment Member benefits summary CVS Caremark
Cycle Limit Generally up to 6 cycles total FDA labeling guidance FDA

Required Forms for Prior Authorization

Primary Form: Besponsa Precertification Request Aetna provides a dedicated Besponsa precertification form that your oncologist must complete. This form requires:

  • Patient demographics and insurance information
  • Complete diagnosis with ICD-10 codes
  • Documentation of CD22-positive status
  • Prior treatment history and failures/intolerance
  • Planned dosing schedule and number of cycles
  • Hepatic function assessment (due to boxed warning for hepatotoxicity)

Additional Documentation Needed:

  • Recent lab results (CBC, comprehensive metabolic panel, liver function tests)
  • Pathology report confirming CD22+ B-cell ALL
  • Treatment history notes documenting prior therapies
  • Oncologist attestation of medical necessity

Clinician Corner: Medical Necessity Letter Checklist

When completing the precertification request, ensure your medical necessity letter addresses:

✓ Problem Statement: "Patient has relapsed/refractory CD22-positive B-cell precursor ALL"
✓ Prior Treatments: List specific agents tried, dates, and reasons for discontinuation
✓ Clinical Rationale: Reference FDA approval and NCCN guidelines for Besponsa
✓ Safety Monitoring: Plan for hepatic monitoring and VOD risk assessment
✓ Treatment Goals: Expected clinical benefit and response monitoring plan

Submission Portals and Electronic Options

Preferred Method: Availity Portal Most providers can submit Aetna prior authorizations through Availity, Aetna's preferred electronic platform. Benefits include:

  • Real-time submission confirmation
  • Faster processing (often 24-48 hours vs. 3-5 days by fax)
  • Ability to track request status
  • Electronic attachment uploads for labs and notes

Alternative: Aetna Provider Portal Some providers access Aetna's systems through the CVS Caremark provider portal for pharmacy-related requests.

Tip: If your practice doesn't have Availity access, the electronic submission often processes faster than fax, so it's worth setting up an account.

Fax Numbers and Mailing Instructions

Primary Fax for Specialty Drug PA Requests:

  • Commercial Plans: 1-888-267-3277
  • Medicare Plans: 1-844-268-7263

Cover Sheet Requirements:

  • Patient name and Aetna member ID
  • Prescriber name and NPI number
  • "URGENT - Specialty Drug Prior Authorization Request"
  • Total number of pages being faxed
  • Contact phone number for questions

Mailing Address (if fax unavailable): Verify current mailing address through the Aetna provider forms page, as addresses can change.

CVS Specialty Pharmacy Transfer Process

Once your prior authorization is approved, Besponsa must be dispensed through CVS Specialty Pharmacy. Here's how to initiate the transfer:

Step-by-Step Transfer Process:

  1. Contact CVS Specialty: Call 1-800-237-2767 (Monday-Friday, 7:30 AM - 9:00 PM EST)
  2. Provide Information: Have your Aetna member ID, prescriber details, and PA approval number ready
  3. Complete Enrollment: CVS will verify insurance, coordinate with your oncologist, and arrange delivery
  4. Choose Delivery Location: Home, doctor's office, or participating CVS Pharmacy locations

What CVS Specialty Handles:

  • Insurance verification and copay calculation
  • Prior authorization coordination with Aetna
  • Cold-chain shipping and delivery scheduling
  • Refill reminders and adherence support
  • Financial assistance program enrollment

Support Lines: Who to Call When

For Providers:

  • Prior Authorization Status: 1-855-240-0535 (Mon-Fri, 8 AM - 6 PM CT)
  • Peer-to-Peer Reviews: Request through the PA status line above
  • General Provider Services: Number on the back of patient's ID card

For Patients/Members:

  • Member Services: Number on back of your Aetna ID card
  • CVS Specialty Pharmacy: 1-800-237-2767
  • Appeals and Grievances: 1-833-741-1361 (CVS Caremark Customer Care)

What to Ask When Calling:

  • Current status of your PA request (reference number helpful)
  • Specific reason if denied and what additional information is needed
  • Timeline for decision and next steps if denied
  • Whether an expedited review is possible for urgent situations

Pennsylvania Appeals Process and External Review

Pennsylvania offers one of the strongest patient appeal processes in the nation. If Aetna denies your Besponsa request, you have multiple levels of appeal.

Internal Appeals with Aetna (Required First Step):

  • Timeline: 180 days from denial to file internal appeal
  • Standard Review: Up to 30 days for decision
  • Expedited Review: 72 hours for urgent situations
  • Submit to: Appeals address on your denial letter or through member portal

Pennsylvania External Review (After Internal Appeal): Pennsylvania's Independent External Review Program launched in 2024 with impressive results—about 50% of appealed denials are overturned.

External Review Process:

  1. Eligibility: Must have completed Aetna's internal appeal process
  2. Timeline: 4 months from final denial letter to request external review
  3. Submission: Online through PA.gov portal or by mail/fax to Pennsylvania Insurance Department
  4. Decision Time: 45 days for standard review, 72 hours for expedited
  5. Cost: Free to consumers
  6. Binding: If approved, Aetna must cover the treatment
From our advocates: We've seen cases where patients received initial denials for specialty oncology drugs, but the external review process in Pennsylvania resulted in coverage approval when the independent medical reviewers found the treatment met clinical guidelines. The key was submitting comprehensive medical records and current treatment guidelines along with the appeal.

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Provide NCCN guidelines and FDA labeling NCCN Guidelines for ALL, FDA prescribing information
"CD22 status not documented" Submit flow cytometry or pathology report Lab report showing CD22-positive expression
"Step therapy not completed" Document prior therapy failures Treatment notes showing intolerance/failure of required first-line agents
"Experimental/investigational" Cite FDA approval for your indication FDA approval letter and prescribing information
"Quantity/dosing exceeds limits" Justify dosing per FDA labeling FDA prescribing information with weight-based dosing

Costs and Financial Assistance

Estimated Costs: Besponsa's wholesale acquisition cost is approximately $8,700 per 0.9-mg vial (verify with current pricing), with total treatment costs varying by number of cycles and patient weight.

Financial Assistance Options:

  • Pfizer Patient Assistance Program: Income-based free drug program
  • Copay Cards: May reduce out-of-pocket costs for commercially insured patients
  • State Pharmaceutical Assistance: Pennsylvania's PACE program for seniors
  • Foundation Grants: Leukemia & Lymphoma Society, Patient Advocate Foundation

Contact CVS Specialty Pharmacy at 1-800-237-2767 to discuss financial assistance options during enrollment.

FAQ: Your Most Common Questions

How long does Aetna prior authorization take for Besponsa in Pennsylvania? Standard PA requests take 3-5 business days by fax, 1-2 days through electronic submission. Expedited reviews for urgent situations are completed within 72 hours.

What if Besponsa isn't on my formulary? You can request a formulary exception using the same precertification process. Provide medical necessity documentation and evidence that preferred alternatives aren't appropriate.

Can I get an expedited appeal if my condition is worsening? Yes. Both Aetna internal appeals and Pennsylvania external reviews offer expedited processes for urgent medical situations. Your oncologist must provide clinical justification for urgency.

Does step therapy apply to Besponsa? Step therapy requirements vary by plan, but for relapsed/refractory ALL, most plans recognize that patients have already failed first-line therapies. Document prior treatment failures clearly.

What happens if I start treatment before PA approval? Aetna typically won't cover treatments started before PA approval. However, you can request retroactive coverage through the appeals process with strong medical justification.

How does Pennsylvania's external review compare to other states? Pennsylvania's program is newer (launched 2024) and has shown higher success rates than the federal process, with about 50% of appeals succeeding versus lower rates in federal external review.

Getting Besponsa covered requires persistence, but Pennsylvania patients have strong appeal rights and resources. Counterforce Health helps patients and providers navigate complex prior authorization and appeals processes by analyzing denial letters, identifying the specific coverage criteria, and drafting evidence-backed appeals that address payers' requirements point-by-point. The platform streamlines what can be an overwhelming process, especially for specialty oncology drugs like Besponsa where clinical documentation requirements are extensive.

If you're facing a denial, remember that many initially denied specialty drug requests are ultimately approved through the appeals process. Pennsylvania's external review program provides an additional safety net, with independent medical reviewers who can overturn insurer decisions when treatments meet clinical guidelines.

For additional help navigating the appeals process in Pennsylvania, contact the Pennsylvania Insurance Department's Consumer Services or consider working with Counterforce Health to ensure your appeal addresses all of Aetna's specific coverage criteria.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and procedures can change. Always verify current requirements with Aetna and consult with your healthcare provider about treatment decisions. For personalized assistance with appeals, consider consulting with a patient advocate or healthcare coverage specialist.

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