By Counterforce Health Team in Enbrel (etanercept) —

How to Get Enbrel (etanercept) Covered by Aetna (CVS Health) in California: Complete Forms, Appeals & Contact Guide

Answer Box: Getting Enbrel (etanercept) Covered by Aetna (CVS Health) in California

Enbrel requires prior authorization from Aetna (CVS Health) with step therapy requirements for most conditions. Your fastest path to approval: 1) Have your doctor submit the California-specific PA form via CVS Caremark portal or fax to 1-877-309-8077, 2) Document any failed biosimilars or conventional treatments, 3) Include medical necessity letter with diagnosis codes and clinical rationale. If denied, California's Independent Medical Review (IMR) through DMHC has a 73% overturn rate. Start with verifying your plan's formulary status today.

Table of Contents

  1. Verify Your Plan and Coverage
  2. Required Forms and Documentation
  3. Submission Portals and Methods
  4. Fax Numbers and Mailing Addresses
  5. CVS Specialty Pharmacy Enrollment
  6. Support Phone Numbers
  7. California Appeals and IMR Process
  8. Common Denial Reasons and Solutions
  9. FAQ
  10. Sources and Further Reading

Verify Your Plan and Coverage

Before starting the prior authorization process, confirm Enbrel's status on your specific Aetna plan. Most Aetna plans in California require prior authorization for Enbrel, with CVS Caremark managing specialty drug benefits.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Aetna plans Aetna Precertification Lists
Step Therapy Must try biosimilars or conventional drugs first Aetna Medical Policy
Specialty Pharmacy Must use CVS Specialty for dispensing CVS Specialty Information
Formulary Tier Specialty tier with higher copays Check your plan's drug guide
Note: If you previously received Enbrel or other biologics, this may bypass step therapy requirements. Document all prior treatments carefully.

Required Forms and Documentation

Primary Forms

The current Aetna California Prior Authorization Form is available through PrescriberPoint or Aetna's healthcare professional forms page. This California-specific version was last updated in 2024.

Essential Documentation Checklist

Clinical Information Required:

  • Primary diagnosis with ICD-10 codes (e.g., M06.9 for rheumatoid arthritis)
  • Complete treatment history with specific medications, dates, and outcomes
  • Documentation of biosimilar failures if applicable
  • Current disease activity measures and severity indicators
  • Contraindications to alternative treatments

Medical Necessity Letter Components:

  • Patient's medical history and current condition
  • Failed treatments with specific names, doses, and duration
  • Clinical rationale for Enbrel specifically
  • Expected treatment goals and monitoring plan
  • Supporting literature or guideline references

Clinician Corner: Step Therapy Documentation

For California Aetna members, step therapy requirements vary by indication:

Rheumatoid Arthritis: Document inadequate response to conventional synthetic DMARDs (methotrexate, leflunomide, sulfasalazine, or hydroxychloroquine) OR prior biologic use.

Psoriatic Arthritis: Show failure of methotrexate, leflunomide, or other conventional drugs for mild-moderate disease.

Ankylosing Spondylitis: Require inadequate response to at least two NSAIDs.

Tip: California law protects patients from repeating failed treatments. If you've tried biosimilars in any state, document this to potentially bypass step therapy.

Submission Portals and Methods

Primary Submission Method: CVS Caremark Provider Portal

Healthcare providers should register at the CVS Caremark provider portal for electronic prior authorization submissions. Registration requires:

  • NPI verification
  • Practice information
  • Electronic signature setup

Portal Benefits:

  • Real-time status tracking
  • Faster processing times
  • Secure document upload for labs and clinical notes
  • Automated renewal reminders

Alternative Submission Options

If portal access isn't available, providers can submit via:

  • Fax: 1-877-309-8077 (include cover sheet with patient/member ID)
  • Phone: 1-800-294-5979 (Monday-Friday, 8 AM-6 PM CST)

Fax Numbers and Mailing Addresses

Key Fax Numbers for Enbrel Prior Authorization

Purpose Fax Number Notes
CVS Caremark PA Submission 1-877-309-8077 Primary fax for all PA requests
Aetna Specialty Medication Precert 1-888-267-3277 Alternative for specialty drugs
Aetna Medicare Advantage Part B 1-844-268-7263 For Part B coverage requests
CVS Specialty Pharmacy (prescriptions) 1-800-323-2445 New prescription transfers

Cover Sheet Requirements

When faxing, include:

  • Patient's full name and member ID
  • Provider NPI and contact information
  • Urgency level (standard or expedited)
  • Complete page count
  • Return fax number for confirmation

CVS Specialty Pharmacy Enrollment

Once Enbrel is approved, CVS Specialty Pharmacy typically handles dispensing for Aetna members. The enrollment process involves:

Automatic Enrollment Process

  1. Prescription Transfer: Your doctor sends the approved Enbrel prescription to CVS Specialty
  2. Patient Contact: CVS Specialty staff will call you within 24-48 hours
  3. Insurance Verification: They confirm coverage and copay information
  4. Delivery Setup: Schedule convenient delivery times and locations
  5. Support Services: Enrollment in patient support programs if eligible

Patient Preparation

Have ready when CVS Specialty calls:

  • Insurance card and member ID
  • Preferred delivery address
  • Contact information for questions
  • ENBREL Co-Pay Card if enrolled in manufacturer program
Tip: If you don't hear from CVS Specialty within 3 business days, call 1-866-782-2779 to check on your prescription status.

Support Phone Numbers

For Patients

Service Phone Number Hours Purpose
Aetna Member Services Number on your insurance card Varies by plan Coverage verification, appeals
CVS Specialty Pharmacy 1-866-782-2779 Mon-Fri 8 AM-8 PM ET Prescription status, delivery
Aetna Specialty Precert 1-866-752-7021 Business hours Prior authorization status

For Healthcare Providers

Service Phone Number Hours Purpose
CVS Caremark Prior Authorization 1-800-294-5979 Mon-Fri 8 AM-6 PM CST PA submissions, status
Aetna Provider Services 1-866-814-5506 Business hours General provider support
Peer-to-Peer Reviews 1-800-294-5979 Mon-Fri 8 AM-6 PM CST Clinical discussions

California Appeals and IMR Process

California offers robust appeal rights through two regulatory agencies: the Department of Managed Health Care (DMHC) for HMOs and most PPOs, and the California Department of Insurance (CDI) for other plans.

Step-by-Step Appeals Process

Level 1: Internal Appeal (Grievance)

  1. File with Aetna within 180 days of denial
  2. Submit via member portal or call member services
  3. Include all supporting documentation
  4. Wait up to 30 days for decision (expedited: 72 hours for urgent cases)

Level 2: Independent Medical Review (IMR)

  1. File with DMHC within 6 months of denial
  2. Submit online at DMHC.ca.gov or call 888-466-2219
  3. Include denial letters, medical records, and physician support
  4. Decision within 45 days (expedited: 7 days for urgent cases)

California IMR Success Rate

Approximately 73% of IMR cases result in overturning the health plan's denial, making this an effective option for denied specialty medications like Enbrel.

Required IMR Documentation

  • Original denial letter from Aetna
  • Complete medical records supporting medical necessity
  • Letter from prescribing physician
  • Any additional clinical evidence or studies
  • Completed IMR application form
Important: IMR decisions are binding on health plans. If approved, Aetna must authorize Enbrel within 5 business days.

Common Denial Reasons and Solutions

Denial Reason How to Overturn Documentation Needed
Step therapy not completed Document biosimilar failures or contraindications Treatment history with specific outcomes
Not medically necessary Provide clinical evidence and guidelines Disease activity measures, physician letter
Non-formulary drug Request formulary exception Comparison to covered alternatives
Quantity limits exceeded Justify dosing based on weight/severity Clinical rationale for higher doses
Experimental/investigational Cite FDA approval and guidelines FDA labeling, professional guidelines

Scripts for Common Situations

Patient Phone Script for Aetna Member Services: "I'm calling about a prior authorization denial for Enbrel (etanercept) for [condition]. My member ID is [number]. I'd like to understand the specific denial reason and start an internal appeal. Can you help me with the appeal form and tell me what additional documentation you need?"

Clinic Staff Script for Peer-to-Peer Review: "I'm requesting a peer-to-peer review for [patient name] who was denied Enbrel coverage. The patient has [specific condition] with documented failure of [list prior treatments]. I have clinical documentation supporting medical necessity and would like to discuss this case with the medical director."

When to Get Additional Help

If your appeal is denied at both internal and IMR levels, consider:

Professional Assistance

Organizations like Counterforce Health specialize in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Their platform identifies the specific denial basis and drafts point-by-point responses aligned with the plan's own rules, significantly improving approval rates for complex specialty medications.

State Consumer Resources

  • DMHC Help Center: 888-466-2219 for complaint assistance
  • Health Consumer Alliance: Nonprofit providing free appeal support
  • Legal Aid: For complex cases involving discrimination or bad faith

FAQ

How long does Aetna prior authorization take for Enbrel in California? Standard decisions take 30-45 days, while expedited appeals for urgent medical situations are typically decided within 72 hours.

What if Enbrel is not on my Aetna formulary? You can request a formulary exception by documenting medical necessity and why covered alternatives are inappropriate for your condition.

Can I request an expedited appeal in California? Yes, if your physician documents that delay would seriously jeopardize your health or ability to function, you can request expedited review at both internal and IMR levels.

Does step therapy apply if I failed treatments in another state? No, California law protects patients from repeating failed treatments. Document any prior treatment failures regardless of where they occurred.

What happens if my IMR is approved but Aetna still won't cover Enbrel? IMR decisions are legally binding. If Aetna doesn't comply within 5 business days, contact the DMHC immediately for enforcement action.

How much will Enbrel cost with Aetna coverage? Costs vary by plan, but specialty tier copays typically range from $100-500 per month. The manufacturer offers copay assistance programs that may reduce out-of-pocket costs.

Can I appeal if I'm on Medicare Advantage through Aetna? Yes, but the process differs slightly. You'll follow Medicare appeal procedures with different timelines and may ultimately appeal to Medicare rather than state agencies.

What if I need Enbrel immediately for a severe flare? Request an expedited prior authorization and appeal if denied. For true emergencies, California law requires coverage of emergency medications with retroactive authorization.

Costs and Patient Assistance

Manufacturer Support Programs

ENBREL Support: Offers copay assistance and patient support services. Eligible patients may pay as little as $5 per month (restrictions apply).

Foundation Grants

  • Patient Advocate Foundation: Provides copay relief for eligible patients
  • HealthWell Foundation: Offers grants for specialty medications
  • Good Days: Assistance for chronic disease treatments

Update Schedule

Prior authorization requirements and forms change periodically. Check for updates:

  • Quarterly: Review Aetna formulary changes
  • Annually: Verify current PA forms and contact information
  • As needed: When switching plans or experiencing denials

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements may vary by specific plan and change over time. Always consult with your healthcare provider and insurance plan for the most current information regarding your specific situation.

Sources and Further Reading

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