By Counterforce Health Team in Eloctate (coagulation factor VIII, rFVIIIFc; efmoroctocog alfa) —

How to Get Eloctate Covered by Aetna CVS Health in Washington: Prior Authorization Guide, Appeals Process, and State Protection Rights

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

Eloctate (efmoroctocog alfa) is covered as a preferred specialty drug by Aetna CVS Health in Washington but requires prior authorization from a hematologist. The fastest path to approval: (1) Have your hematologist submit a complete prior authorization with hemophilia A diagnosis, bleeding history, and dosing justification to CVS Caremark Specialty, (2) If denied, file an internal appeal within 180 days, and (3) Use Washington's binding Independent Review Organization (IRO) process for final decisions. Washington state law provides strong patient protections with 15-day IRO decisions that are binding on Aetna.

First step today: Contact your hematologist to begin the prior authorization process using Aetna's specialty PA forms.

Table of Contents

Why Washington State Rules Matter

Washington provides some of the nation's strongest patient protections for specialty medication appeals. Under RCW 48.43.535, patients have the right to binding external review by Independent Review Organizations (IROs) when Aetna denies coverage based on medical necessity.

Key Washington protections include:

  • Binding IRO decisions that Aetna must follow
  • 15-day standard review (72 hours for urgent cases)
  • No cost to patients for external review
  • Medical necessity standard rather than just contract language
  • Automatic approval if Aetna fails to respond to emergency requests within 24 hours

These state rules apply to most Aetna plans in Washington, though self-funded employer plans (ERISA) may have different procedures.

Coverage at a Glance

Requirement Details Source
Prior Authorization Required from hematologist Aetna PA List
Formulary Status Preferred specialty drug Aetna Specialty Drug List
Step Therapy Not required Aetna Policy
Specialty Pharmacy CVS Caremark or contracted specialty pharmacy CVS Specialty
Authorization Period 12 months with annual renewal Standard practice
Appeals Deadline 180 days from denial Aetna Appeals

Fastest Path to Approval

Step 1: Gather Required Documentation

Who: Patient and clinic staff
Timeline: 1-2 days
Documents needed:

  • Insurance card and member ID
  • Complete hemophilia A diagnosis with ICD-10 code D66
  • Detailed bleeding history and prior factor VIII treatments
  • Current weight and dosing calculations
  • Lab results including inhibitor testing (Bethesda assay)

Step 2: Hematologist Submits Prior Authorization

Who: Hematologist or clinic staff
Timeline: Submit immediately
How: Use Aetna's provider portal or fax to specialty PA department
Required: Complete PA form with medical necessity letter

Step 3: CVS Caremark Review

Who: CVS Caremark medical reviewers
Timeline: 30-45 days standard, 72 hours urgent
Process: Clinical review against Aetna's hemophilia A criteria

Step 4: Specialty Pharmacy Coordination

Who: CVS Specialty Pharmacy
Timeline: Upon approval
Next steps: Coordinate delivery and patient education

Tip: Request expedited review if patient has active bleeding or is at high risk. Provide clear clinical justification for urgency.

Prior Authorization Requirements

Aetna requires comprehensive clinical documentation for Eloctate approval. Based on current PA criteria, your hematologist must provide:

Medical Necessity Letter Must Include:

  • Confirmed hemophilia A diagnosis with ICD-10 code D66
  • Bleeding history with frequency and severity of episodes
  • Prior factor VIII treatments (if any) with outcomes, failures, or intolerances
  • Inhibitor testing results (Bethesda assay)
  • Weight-based dosing justification for prophylaxis or on-demand treatment
  • Clinical rationale for choosing Eloctate over other factor VIII products
  • Treatment goals and monitoring plan

Supporting Documentation:

  • Recent lab results and coagulation studies
  • Bleeding diary or episode logs
  • Previous treatment records
  • Specialist consultation notes

Counterforce Health helps patients and clinicians streamline this complex prior authorization process by automatically generating evidence-backed appeals that align with each payer's specific requirements. Our platform identifies the exact documentation Aetna needs and drafts targeted medical necessity letters that cite relevant FDA labeling, clinical guidelines, and patient-specific factors. Learn more about our services.

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
Non-preferred brand Submit formulary exception request Comparative effectiveness data, prior failures
Dosing over limits Provide weight-based calculations Current weight, bleeding pattern, PK studies
Not prescribed by specialist Transfer to hematologist Specialist consultation and ongoing care plan
Insufficient clinical information Resubmit with complete records Full bleeding history, lab results, treatment goals
"Not medically necessary" File appeal with guidelines FDA labeling, WFH guidelines, peer-reviewed studies

Appeals Process in Washington

Washington's structured appeals process provides multiple opportunities to overturn denials:

Internal Appeal (Level 1)

  • Deadline: 180 days from denial notice
  • Timeline: 30 days standard, 14 days urgent
  • How to file: Aetna member portal or written request
  • Include: All supporting clinical documentation, provider letters

Peer-to-Peer Review

  • Available: Upon request during internal appeal
  • Process: Your hematologist speaks directly with Aetna's medical director
  • Benefits: Often resolves complex cases without formal appeal

External Review (IRO Process)

If internal appeals are denied, Washington law guarantees access to binding external review:

  • Deadline: 21 days after final internal denial
  • How to request: Contact Washington Office of Insurance Commissioner at 1-800-562-6900
  • Timeline: 15 business days (72 hours for urgent)
  • Cost: Free to patients
  • Decision: Binding on Aetna

The Washington OIC provides template appeal letters and consumer advocacy support throughout the process.

Washington's External Review Protection

Washington's Independent Review Organization process offers unique advantages:

Key Protections Under RCW 48.43.535:

  • Medical necessity standard: IRO reviews based on medical evidence, not just contract language
  • Specialist reviewers: IRO panels include hematologists familiar with hemophilia care
  • Binding decisions: Aetna must comply with IRO determinations
  • Expedited process: 72-hour decisions for urgent cases
  • Automatic approval: If Aetna fails to respond to emergency requests within 24 hours

How to Strengthen Your IRO Case:

  1. Submit comprehensive medical records including bleeding diaries and treatment responses
  2. Include peer-reviewed literature supporting Eloctate's clinical benefits
  3. Provide specialist attestation of medical necessity
  4. Document any adverse effects from alternative treatments
  5. Cite relevant clinical guidelines from the World Federation of Hemophilia
From our advocates: "We've seen patients successfully overturn Aetna denials through Washington's IRO process by focusing on individualized medical necessity rather than just formulary status. The key is providing comprehensive documentation that shows why Eloctate specifically meets the patient's clinical needs."

Costs and Financial Assistance

Eloctate's high cost (approximately $2.68 per IU at wholesale) makes financial assistance crucial:

Manufacturer Support:

  • Sobi Cares patient assistance program
  • Copay assistance for eligible commercially insured patients
  • Free drug programs for uninsured qualifying patients

Additional Resources:

  • Hemophilia Federation of America emergency financial assistance
  • National Hemophilia Foundation state chapter support programs
  • Washington state pharmaceutical assistance programs through DSHS

Contact these programs early in the approval process to avoid treatment delays.

When to Contact State Regulators

Contact the Washington Office of Insurance Commissioner if:

  • Aetna fails to respond within required timeframes
  • You need help understanding your appeal rights
  • The internal appeal process seems unfair or incomplete
  • You want to file a complaint about coverage practices

Consumer Hotline: 1-800-562-6900
Online complaints: Available through the OIC website with tracking capabilities

The OIC can provide personalized guidance and intervene when insurers don't follow Washington's consumer protection laws.

FAQ

How long does Aetna prior authorization take in Washington?
Standard PA decisions take 30-45 days, while urgent requests are processed within 72 hours. Aetna's utilization management guidelines specify these timeframes for Washington members.

What if Eloctate is non-formulary on my plan?
Even if non-formulary, you can request a formulary exception with medical necessity documentation. Aetna must provide a pathway to access medically necessary treatments regardless of formulary status.

Can I request an expedited appeal?
Yes, if you're at risk of serious harm from delayed treatment. Your hematologist must document the urgency and potential health consequences of waiting for standard review.

Does step therapy apply if I've used other factor VIII products outside Washington?
Prior treatment history follows you regardless of location. Document all previous factor VIII therapies and their outcomes to support your Eloctate request.

What happens if my appeal is denied?
You have the right to external review through Washington's IRO process. This provides an independent medical opinion that's binding on Aetna.

How often do I need to renew prior authorization?
Eloctate PA typically requires annual renewal with updated clinical information, including treatment response and any changes in bleeding patterns.

Can Counterforce Health help with my appeal?
Yes, Counterforce Health specializes in turning insurance denials into successful appeals by identifying specific denial reasons and crafting evidence-backed responses that align with Aetna's requirements and Washington state protections.

What if I have an ERISA plan through my employer?
Self-funded employer plans may not be subject to all Washington state protections, but many voluntarily adopt similar processes. Contact your plan administrator for specific appeal procedures.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. Coverage policies may vary by plan type and individual circumstances. For personalized assistance with your specific situation, contact the Washington Office of Insurance Commissioner or consider working with a patient advocacy service.

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