By Counterforce Health Team in Enbrel (etanercept) —

How to Get Enbrel (etanercept) Covered by Aetna (CVS Health) in Pennsylvania: Complete Appeals Guide with Forms and Timelines

Answer Box: Getting Started with Enbrel (etanercept) Coverage

Aetna (CVS Health) requires prior authorization for Enbrel (etanercept) in Pennsylvania. Start by having your doctor submit the Aetna specialty pharmacy prior authorization form with documentation of diagnosis, prior treatment failures, and medical necessity. If denied, you can appeal internally through Aetna and then request an external review through Pennsylvania's Insurance Department, which overturns about 50% of denials. First step today: Log into your Aetna member portal to verify coverage details and download the PA form.

Table of Contents

  1. Start Here: Verify Your Plan and Find Forms
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Upload Instructions
  4. Fax Numbers and Mailing Addresses
  5. CVS Caremark Specialty Pharmacy Enrollment
  6. Support Phone Lines and What to Ask
  7. Pennsylvania External Review Process
  8. Common Denial Reasons and How to Fix Them
  9. Appeals Timeline and Deadlines
  10. FAQ

Start Here: Verify Your Plan and Find the Right Forms

Before diving into prior authorization, confirm your specific Aetna plan details. Pennsylvania has strengthened insurance protections under Act 77 of 2024, which governs specialty drug coverage including Enbrel.

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all Enbrel prescriptions Aetna member portal
Formulary Tier Specialty tier (high copay) Member portal or call member services
Step Therapy May require biosimilar trial first CVS Caremark PA form
Specialty Pharmacy Must use accredited specialty pharmacy CVS Caremark Specialty
Appeals Deadline 180 days from denial notice Denial letter instructions
Tip: Pennsylvania's Act 77 requires that specialty drugs like Enbrel be dispensed through nationally accredited specialty pharmacies. This ensures proper handling and monitoring.

Prior Authorization Forms and Requirements

Medical Necessity Documentation

Your prescribing physician must submit comprehensive documentation including:

  • Diagnosis with ICD-10 codes (e.g., rheumatoid arthritis, psoriatic arthritis, plaque psoriasis)
  • Prior treatment history with specific medications, dates, and outcomes
  • Documentation of biosimilar failures if step therapy applies
  • Clinical justification for Enbrel specifically
  • Dosing rationale and treatment goals

Required Forms

  1. Primary Form: Aetna Enbrel Prior Authorization Form
  2. Step Therapy Override: If you've failed biosimilars, document this clearly
  3. Medical Records: Recent clinic notes supporting diagnosis and treatment history
Clinician Corner: When documenting biosimilar failure, include specific drug names, dosages, treatment duration, and reason for discontinuation (lack of efficacy, adverse reactions, contraindications). Pennsylvania law prohibits requiring patients to repeat failed treatments.

Submission Portals and Upload Instructions

Primary Submission Methods

Aetna Member Portal

  • Log in with your member credentials
  • Navigate to prescription benefits section
  • Upload PA forms and supporting documents
  • Track submission status in real-time

Provider Portal

  • Physicians should use the Aetna provider portal for fastest processing
  • Electronic submission reduces processing time
  • Automatic confirmation and tracking available

Document Upload Tips

  • File formats: PDF preferred; ensure documents are clear and legible
  • Naming convention: Use patient name and document type (e.g., "Smith_John_PA_Form.pdf")
  • Size limits: Most portals accept files up to 10MB
  • Required attachments: Always include the denial letter if appealing

Fax Numbers and Mailing Addresses

CVS Caremark Specialty Programs

  • Fax: 1-866-237-5512
  • Use for: Prior authorization submissions, appeals, supporting documentation

Aetna Provider Relations (Pennsylvania)

  • Fax: 1-860-754-5435
  • Phone: 1-866-638-1232 (Monday-Friday, 8 AM-5 PM)
  • Use for: Provider inquiries, unresolved portal issues

Cover Sheet Best Practices

When faxing documents:

  • Include patient name, date of birth, and member ID
  • List all attached documents
  • Mark "URGENT" for expedited requests
  • Include callback number for questions

CVS Caremark Specialty Pharmacy Enrollment

Under Pennsylvania law, Enbrel must be dispensed through an accredited specialty pharmacy. Here's how to enroll:

Step-by-Step Enrollment Process

  1. Complete Prior Authorization (required before enrollment)
  2. Call CVS Caremark Specialty at the number provided in your approval letter
  3. Provide Required Information:
    • Insurance details and member ID
    • Prescriber information
    • Shipping address and preferences
  4. Schedule Delivery (typically within 24-48 hours of approval)

Transfer from Another Specialty Pharmacy

If you're currently using a different specialty pharmacy:

  • Use the CVS transfer portal or call directly
  • Provide current prescription details
  • CVS will coordinate with your current pharmacy
  • No interruption in therapy during transfer
From Our Advocates: We've seen patients successfully transfer to CVS Caremark within 2-3 business days when they proactively contact both the old and new pharmacies with their prescription details and insurance information. Having your member ID and prescriber's contact information ready speeds up the process significantly.

Support Phone Lines and What to Ask

Aetna Member Services

  • Phone: Number on back of insurance card
  • Best times to call: Early morning or late afternoon
  • What to ask:
    • "What's the status of my Enbrel prior authorization?"
    • "What specific documentation is needed for approval?"
    • "Can you expedite this request due to medical urgency?"

CVS Caremark Specialty

  • Phone: Provided after PA approval
  • Services: Enrollment, delivery scheduling, clinical support
  • 24/7 pharmacist consultation available

Pennsylvania Insurance Department

  • Consumer Services: 1-877-881-6388
  • Use for: External review guidance, complaint filing, general insurance questions

Pennsylvania External Review Process

Pennsylvania launched its Independent External Review Program in January 2024, with impressive results: about 50% of appealed denials are overturned.

When to Request External Review

  • After receiving a "Final Adverse Benefit Determination" from Aetna
  • Within 4 months of the final internal denial
  • For denials based on medical necessity, experimental treatment, or coverage disputes

How to Submit

  1. Download the form from the Pennsylvania Insurance Department website
  2. Gather required documents:
    • Final denial letter from Aetna
    • All supporting medical records
    • Your completed external review request form
  3. Submit via:
    • Online portal (preferred)
    • Fax or email (as specified on the form)
    • Regular mail

Timeline and Outcomes

  • Standard review: 45 days from IRO assignment
  • Expedited review: 72 hours for urgent cases
  • Additional evidence: You can submit more documentation within 15 days
  • Binding decision: If approved, Aetna must provide coverage immediately

Counterforce Health helps patients navigate complex insurance appeals by analyzing denial letters and crafting targeted, evidence-backed responses that align with payer policies. Their platform has helped numerous patients get specialty medications like Enbrel approved by identifying the specific denial reasons and providing point-by-point rebuttals.

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn Required Documentation
Step therapy required Document biosimilar failure Treatment dates, outcomes, adverse reactions
Not medically necessary Provide clinical evidence Diagnosis confirmation, treatment history, guidelines
Non-formulary status Request formulary exception Medical necessity letter, cost comparison
Quantity limits exceeded Justify dosing requirements Weight-based calculations, clinical response
Inadequate documentation Submit complete records All clinic notes, lab results, imaging

Step Therapy Override Documentation

Pennsylvania law protects patients from repeating failed treatments. To override step therapy:

  • Document specific biosimilar used (name, dose, duration)
  • Reason for discontinuation (inefficacy, intolerance, contraindication)
  • Clinical evidence of failure (lab values, symptom progression)
  • Medical rationale for Enbrel specifically

Appeals Timeline and Deadlines

Internal Appeal Process

Stage Timeline Action Required
Initial denial Day 0 Review denial letter carefully
Internal appeal filing Within 180 days Submit appeal form with evidence
Aetna decision 30-45 days (72 hours if urgent) Await determination
Final adverse determination If denied Prepare for external review

External Review Process

Stage Timeline Action Required
External review request Within 4 months of final denial Submit PA Insurance Dept form
IRO assignment 5-10 business days Review assignment notice
Additional evidence period 15 days from assignment Submit any new documentation
Final decision 45 days (72 hours if expedited) Binding determination
Note: Pennsylvania's external review success rate of approximately 50% makes it a valuable option for patients who've exhausted internal appeals.

FAQ

How long does Aetna prior authorization take for Enbrel in Pennsylvania? Standard decisions take 30-45 days, but urgent requests are processed within 72 hours. Electronic submissions through the provider portal are typically faster than fax submissions.

What if Enbrel is not on my formulary? You can request a formulary exception by providing medical necessity documentation. Your doctor must demonstrate that formulary alternatives are inappropriate for your specific condition.

Can I request an expedited appeal? Yes, if your health condition requires urgent treatment. Your doctor must provide documentation that delay would seriously jeopardize your health or ability to function.

Does step therapy apply if I've failed biosimilars outside Pennsylvania? Yes, documented failures from any state should be accepted. Pennsylvania law prohibits requiring patients to repeat failed treatments regardless of where the failure occurred.

What's the difference between internal and external appeals? Internal appeals are reviewed by Aetna staff, while external reviews are conducted by independent medical experts through Pennsylvania's Insurance Department. External reviews have binding decisions.

How much does Enbrel cost without insurance? The list price exceeds $100,000 annually. If your appeal is successful, Aetna will cover the medication according to your plan's specialty tier copay structure.

Can I use manufacturer copay assistance? Yes, Amgen offers patient assistance programs. However, check if your plan allows manufacturer copay cards, as some insurers have restrictions.

What happens if I miss an appeal deadline? Contact the Pennsylvania Insurance Department at 1-877-881-6388 immediately. In some cases, exceptions may be made for good cause, such as serious illness or lack of proper notice.

For complex cases requiring detailed appeal strategies, Counterforce Health provides specialized support in analyzing denial letters and developing evidence-backed responses that address payer-specific requirements and maximize approval chances.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and coverage decisions vary by individual plan. Always consult with your healthcare provider and insurance company for specific guidance regarding your coverage. For additional support with insurance appeals in Pennsylvania, contact the Pennsylvania Insurance Department's Consumer Services at 1-877-881-6388.

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