By Counterforce Health Team in Givlaari (givosiran) —

How to Get Givlaari (Givosiran) Covered by Aetna CVS Health in Washington: Complete Forms, Appeals Guide & Contact Numbers

Quick Answer: Getting Givlaari (Givosiran) Covered by Aetna CVS Health in Washington

Path to approval: Submit Aetna's Givlaari precertification form with biochemical confirmation (elevated ALA/PBG levels), documented attack history (≥2 qualifying attacks in 6-12 months), and specialist evaluation. If denied, file internal appeal within 180 days, then request external review through Washington's Insurance Commissioner. First step today: Verify your Aetna plan covers specialty medications and ask your prescriber to complete both the Aetna PA form and manufacturer's Start Form simultaneously to avoid delays.

Table of Contents

  1. Verify Your Aetna CVS Health Plan Coverage
  2. Required Forms and Documentation
  3. Submission Methods: Portals, Fax & Mail
  4. CVS Specialty Pharmacy Enrollment
  5. Coverage Requirements at a Glance
  6. Common Denial Reasons & Solutions
  7. Appeals Process in Washington
  8. Contact Numbers & Support Lines
  9. Cost Assistance Programs
  10. FAQ: Givlaari Coverage with Aetna CVS Health

Verify Your Aetna CVS Health Plan Coverage

Before starting the prior authorization process, confirm your specific Aetna plan includes specialty drug benefits. Log into your Aetna member portal or call the member services number on your insurance card to verify:

  • Specialty pharmacy network: Most Aetna plans use CVS Specialty for high-cost medications like Givlaari
  • Prior authorization requirements: Givlaari requires precertification for all Aetna commercial and Medicare plans
  • Formulary status: Check if Givlaari is on your plan's formulary or requires an exception
Tip: Washington residents with Aetna through the state exchange (Washington Healthplanfinder) have the same appeal rights as other commercial plans.

Required Forms and Documentation

Primary Forms Needed

1. Aetna Givlaari Precertification Request Form

2. Manufacturer Start Form

  • Access through Alnylam Assist
  • Enables coordination between insurance and specialty pharmacy
  • Patient signature required for benefit verification

Essential Clinical Documentation

Your prescriber must attach:

  • Biochemical confirmation: Elevated delta-aminolevulinic acid (ALA) and porphobilinogen (PBG) levels during attacks
  • Attack history: Documentation of ≥2 qualifying acute hepatic porphyria attacks in the past 6-12 months
  • Prior treatments: Records of hemin use, hospitalizations, or emergency department visits
  • Genetic testing: Confirmation of AHP subtype (if available)
  • Specialist evaluation: Notes from hepatologist, hematologist, or geneticist familiar with porphyria
Clinician Corner: Include specific attack dates, severity scores, and functional impact. Aetna's medical policy emphasizes recurrent attacks requiring medical intervention as the primary coverage criterion.

Submission Methods: Portals, Fax & Mail

Electronic Submission (Fastest)

Aetna Provider Portal

  • URL: Aetna NaviNet Portal (verify current link)
  • Upload PA requests and supporting documentation
  • Track approval status in real-time
  • Typical response: 3-5 business days

Fax Submission

Prior Authorization Fax Numbers (verify with current Aetna materials):

  • Commercial plans: Check your specific precertification form for current fax number
  • Medicare Part D: Use fax number listed on member's EOB or ID card
  • Include cover sheet with member ID and "URGENT" if expedited review needed

Mail Submission

Send completed forms and documentation to the address specified on your Aetna precertification form. Include:

  • Copy of member ID card
  • All supporting clinical documentation
  • Return receipt requested for tracking

CVS Specialty Pharmacy Enrollment

Once Aetna approves Givlaari coverage, CVS Specialty will contact you directly to:

  1. Complete intake process (identity verification, shipping address, allergies)
  2. Verify copay assistance enrollment
  3. Schedule monthly deliveries to clinic or home
  4. Coordinate injection training if needed

CVS Specialty Contact: Call the number provided in your approval letter or check your Aetna member portal for assigned specialty pharmacy details.

Coverage Requirements at a Glance

Requirement Details Documentation Needed Source
Prior Authorization Required for all plans Completed PA form Aetna Policy
Diagnosis Acute hepatic porphyria (any subtype) ICD-10 codes, genetic testing FDA Label
Attack History ≥2 qualifying attacks in 6-12 months ER records, hospitalization notes Aetna Medical Policy
Biochemical Proof Elevated ALA/PBG during attacks Lab results from attacks Clinical Documentation
Prescriber Specialist preferred Hepatologist, hematologist, geneticist PA Form Requirements
Site of Care Clinic or home administration Administration plan CVS Specialty

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Evidence
"Insufficient attack history" Document all attacks, including those treated at home Emergency records, hemin use logs, symptom diaries
"Missing biochemical confirmation" Obtain lab results from attack periods ALA/PBG levels during symptomatic episodes
"Non-specialist prescriber" Transfer care or obtain specialist consultation Referral to hepatologist or hematologist
"Experimental/investigational" Cite FDA approval and medical necessity FDA approval letter, clinical guidelines
"Step therapy required" Document hemin failures or intolerance Treatment history, adverse reactions

Appeals Process in Washington

Washington residents have strong appeal rights under RCW 48.43.535.

Internal Appeals (Required First Step)

Timeline: File within 180 days of denial Process: Submit written appeal to address on denial letter Decision: Standard appeals decided within 30-45 days; expedited within 72 hours Required: Copy of denial letter, new supporting evidence, member statement

External Review (Independent Review Organization)

If internal appeal fails, request external review through:

Washington Insurance Commissioner

  • Phone: 1-800-562-6900 (Consumer Advocacy)
  • Website: Insurance.wa.gov Appeals Guide
  • Timeline: 180 days from final internal denial to request external review
  • Decision: Binding determination within 30 days (expedited: 72 hours)
Note: The IRO decision is binding on Aetna if it overturns the denial. Washington maintains a registry of certified independent review organizations with medical specialists.

Counterforce Health helps patients and clinicians navigate complex prior authorization and appeals processes by analyzing denial letters, identifying specific coverage gaps, and drafting targeted appeals with evidence-based rebuttals. Their platform streamlines the documentation process and increases approval rates for specialty medications like Givlaari.

Contact Numbers & Support Lines

Aetna Member Services

  • Main number: Use number on your member ID card
  • Pharmacy benefits: 1-800-CVS-RX01 (verify current number)
  • Appeals department: Number provided on denial letters

Provider Support

  • Provider services: Check Aetna provider portal for current contact
  • Peer-to-peer review: Request through provider portal or PA form
  • Case management: Available for complex cases

Washington State Resources

  • Insurance Commissioner Consumer Line: 1-800-562-6900
  • Washington Healthplanfinder: 1-855-923-4633
  • Apple Health (Medicaid): 1-800-562-3022

Cost Assistance Programs

Manufacturer Support

Alnylam Assist Program

  • Website: AlnylamAssist.com
  • Services: Copay assistance, patient assistance program, benefit verification
  • Eligibility: Income-based for uninsured; copay support for commercially insured

Additional Resources

  • Patient Access Network (PAN) Foundation: Copay assistance for rare diseases
  • Washington Prescription Drug Program: State-specific assistance options

FAQ: Givlaari Coverage with Aetna CVS Health

Q: How long does Aetna prior authorization take for Givlaari in Washington? A: Standard review takes 3-5 business days with complete documentation. Expedited reviews (for urgent medical situations) are decided within 72 hours.

Q: What if Givlaari isn't on my Aetna formulary? A: Request a formulary exception by documenting medical necessity and lack of suitable alternatives. Your prescriber can submit this with the PA request.

Q: Can I appeal if I'm denied for "experimental" use? A: Yes. Givlaari has FDA approval for acute hepatic porphyria. Cite the FDA approval and provide clinical evidence of medical necessity in your appeal.

Q: Does step therapy apply to Givlaari? A: Some Aetna plans require trial of hemin first. Document hemin failures, intolerance, or inadequate response to request step therapy exception.

Q: What's the difference between internal and external appeals? A: Internal appeals are reviewed by Aetna. External appeals in Washington are reviewed by independent medical experts through the Insurance Commissioner's IRO process.

Q: How much does Givlaari cost with Aetna coverage? A: Costs vary by plan. With copay assistance, many patients pay $0-$20 per month. Contact Alnylam Assist for specific cost estimates.

Q: Can I use any specialty pharmacy besides CVS? A: Check your plan's specialty pharmacy network. Most Aetna plans designate CVS Specialty, but some allow alternatives within their network.

Q: What if my employer plan is self-funded? A: Self-funded ERISA plans may not be subject to Washington state appeal laws. Contact the U.S. Department of Labor for ERISA plan appeals guidance.

From our advocates: "We've seen Givlaari approvals succeed when prescribers include detailed attack logs with specific dates, symptoms, and medical interventions. One Washington patient's appeal was approved after we helped document three emergency department visits in six months, each with elevated porphyrin levels during attacks."

For complex cases requiring detailed appeal strategy, Counterforce Health offers specialized support in analyzing denial patterns and crafting evidence-based appeals that align with payer-specific requirements.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice. Always consult with your healthcare provider about treatment decisions and contact your insurance company or the Washington Insurance Commissioner for plan-specific guidance.

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