By Counterforce Health Team in Humira (adalimumab) —

How to Get Humira (adalimumab) Covered by Aetna (CVS Health) in California: Complete 2025 Guide with Forms and Appeals

Answer Box: Fastest Path to Humira Coverage with Aetna in California

Aetna requires prior authorization for Humira (adalimumab) with step therapy to preferred biosimilars first. To get coverage: 1) Submit PA via CVS Caremark ePA portal with specialist prescription, TB/hepatitis B screening, and documented biosimilar failures, 2) If denied, file internal appeal within 60-180 days with medical necessity letter, 3) Request California Independent Medical Review (IMR) through DMHC if still denied—California patients win 55-68% of medical necessity appeals. Start today by calling Aetna Member Services at the number on your insurance card to verify PA requirements.

Table of Contents

What Drives Your Humira Costs with Aetna

Aetna has moved Humira to non-preferred tiers while favoring lower-cost adalimumab biosimilars as preferred alternatives. This tier placement directly affects your copay, with biosimilars positioned at lower cost-sharing levels than brand-name Humira.

Formulary Changes in 2024-2025

CVS Caremark (Aetna's pharmacy benefit manager) removed Humira from major national commercial formularies effective April 1, 2024, requiring step therapy to preferred adalimumab biosimilars including:

  • Amjevita (adalimumab-atto)
  • Cyltezo (adalimumab-adbm)
  • Abrilada (adalimumab-afzb)
  • Hadlima (adalimumab-bwwd)
Note: Your specific plan's formulary document will show exact tier placement and copay amounts. Access this through your Aetna member portal or by calling the number on your insurance card.

Coverage Investigation: What to Ask Aetna

Before starting treatment, gather this essential information by calling Aetna Member Services:

Key Questions to Ask

  1. "Is Humira covered on my plan's formulary, and what tier?"
  2. "What prior authorization requirements apply?"
  3. "Are there step therapy requirements for adalimumab products?"
  4. "What's my copay for Humira versus biosimilar alternatives?"
  5. "Must I use CVS Specialty Pharmacy?"

Information to Record

  • Policy/group number and member ID
  • Plan name and effective dates
  • Formulary tier for Humira and biosimilars
  • Prior authorization form numbers
  • Appeals deadlines and contact information

Assistance Options for Commercial Insurance

Manufacturer Copay Assistance

AbbVie's Humira Complete Savings Card offers eligible patients with commercial insurance coverage as low as $5 per month, with up to $14,000 maximum annual benefit per calendar year.

Eligibility restrictions:

  • Commercial insurance only (not Medicare, Medicaid, TRICARE, or other government programs)
  • California residents follow national eligibility requirements
  • Copay maximizer programs may limit assistance to $4,000 annually

How to enroll: Contact AbbVie at 1-800-4HUMIRA or visit AbbVie.com/PatientAccessSupport.

Alternative Financial Assistance

If you lack commercial insurance, myAbbVie Assist provides medications at no cost to eligible uninsured patients. Biosimilar manufacturers also offer patient assistance programs with varying eligibility criteria.

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient/Clinic)

  • Insurance card and policy information
  • Specialist prescription (rheumatologist, dermatologist, or gastroenterologist)
  • Complete medical records showing diagnosis and severity
  • Prior therapy documentation (dates, outcomes, reasons for discontinuation)

2. Complete Safety Screenings (Clinic)

Submit these lab results with your PA to avoid delays:

Screening Requirements Timeline
Tuberculosis Negative QuantiFERON-Gold, TST, or IGRA Within 12 months
Hepatitis B HBV panel (HBsAg, anti-HBs, anti-HBc) showing no active infection Current
Other Labs CBC, liver function tests Current

3. Submit Prior Authorization (Clinic)

  • Method: CVS Caremark ePA portal (preferred for speed)
  • Include: All documentation, medical necessity letter, lab results
  • Timeline: 15-45 days standard; 72 hours expedited if health would deteriorate

4. Track Your Request (Patient)

  • Monitor via Aetna member portal
  • Follow up if no response within stated timeframes
  • Request expedited review if medically urgent

When Biosimilars Are Required First

Aetna typically requires step therapy documentation showing trial and inadequate response to preferred adalimumab biosimilars before covering brand-name Humira.

Acceptable Step Therapy Documentation

  • Clinical trial records with dates, dosing, duration
  • Inadequate response despite appropriate trial period
  • Intolerance or adverse effects requiring discontinuation
  • Contraindications preventing biosimilar use

Formulary Exception Process

If Humira is medically necessary despite biosimilar availability:

  1. Submit formulary exception request with medical necessity letter
  2. Include evidence of biosimilar failures or contraindications
  3. Cite clinical guidelines supporting Humira use
  4. Request peer-to-peer review if initially denied

Appeals Playbook for California

California offers robust appeal rights through two regulatory agencies depending on your plan type.

Internal Appeals (First Step)

Timeline: File within 60-180 days of denial notice Process: Submit via Aetna member portal or mail with:

  • Copy of denial letter
  • Medical necessity letter from prescriber
  • Supporting clinical documentation
  • Request for peer-to-peer review (10-15 minute physician call)

California Independent Medical Review (IMR)

For DMHC-regulated plans (most HMOs and managed care plans):

Success rates: 55-68% overturn rate for medical necessity denials Timeline: File within 6 months of internal appeal exhaustion Process: Submit online at healthhelp.ca.gov with:

  • Denial letters from internal appeals
  • Complete medical records
  • Physician statement on medical necessity
From our advocates: We've seen patients succeed with IMR by including detailed documentation of biosimilar trials and failures, along with specialist letters explaining why Humira specifically is medically necessary for their condition. The key is thorough documentation of what's been tried and why alternatives won't work.

DMHC Help Center: 888-466-2219 for assistance filing complaints or IMR requests

For CDI-regulated plans, contact the CDI Consumer Hotline at 800-927-4357 for external review guidance.

CVS Specialty Pharmacy Process

Aetna requires CVS Specialty Pharmacy for Humira dispensing. Here's what to expect:

Prescription Process

  1. Physician submits: ePrescribe to CVS Specialty (ID: 1466033) or fax 1-877-408-9743
  2. Insurance verification: CVS coordinates with Aetna for PA approval (typically few days)
  3. Patient intake: CVS contacts you for delivery coordination and injection training
  4. Dispensing: Shipped refrigerated with ice packs for immediate fridge storage

Important Notes

  • No automatic refills due to cost—set calendar reminders
  • Refrigerated storage required immediately upon delivery
  • CVS CareTeam handles transitions between Humira and biosimilars

CVS Specialty contact: Use the number provided in your welcome materials or contact Aetna for current phone support.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Step therapy not met Document biosimilar trials and failures Trial dates, outcomes, adverse effects
Missing safety screening Submit complete lab results TB, hepatitis B, CBC, LFTs
Not medically necessary Medical necessity letter from specialist Diagnosis, severity, treatment goals
Quantity limits exceeded Justify dosing based on FDA labeling Weight-based calculations, specialist rationale
Non-formulary status Request formulary exception Evidence biosimilars inappropriate

Scripts for Key Conversations

Calling Aetna Member Services

"Hi, I'm calling about prior authorization requirements for Humira, adalimumab, for [condition]. Can you tell me:

  • Is this covered on my formulary and what tier?
  • What PA requirements apply?
  • Are there step therapy requirements?
  • What's my expected copay?
  • Do I need to use CVS Specialty Pharmacy?"

Requesting Peer-to-Peer Review

"I'm requesting a peer-to-peer review for the denied prior authorization. The denial was based on [reason from letter]. I have additional clinical information showing medical necessity. When can we schedule the physician-to-physician call?"

FAQ

How long does Aetna prior authorization take in California? Standard PA decisions take 15-45 days; expedited reviews for urgent situations are completed within 72 hours.

What if Humira is non-formulary on my plan? Request a formulary exception with documentation that preferred biosimilars are inappropriate, contraindicated, or have failed.

Can I appeal if step therapy requirements seem unreasonable? Yes, file an internal appeal within 60-180 days, then pursue California IMR if denied. Success rates are 55-68% for medical necessity cases.

Does the Humira copay card work with Aetna? Yes, for commercial Aetna plans. The card offers coverage as low as $5 per month for eligible patients, with annual maximums.

What happens if I miss the appeal deadline? Appeal deadlines are strict. Contact the DMHC Help Center (888-466-2219) immediately if you believe you have grounds for an extension.

Can I switch from a biosimilar back to Humira? Yes, if you experience inadequate response or intolerance to the biosimilar. Document the issues and request a formulary exception or appeal.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with each payer's specific requirements, incorporating the right clinical evidence and procedural details that payers expect. Visit www.counterforcehealth.org to learn how we can help streamline your prior authorization and appeals process.

For additional support with complex appeals or when facing repeated denials, consider working with Counterforce Health to ensure your appeal addresses the specific criteria and evidence requirements that Aetna uses in their coverage decisions.

Sources & Further Reading

This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about treatment decisions and work with your insurance plan's official processes for coverage determinations. For assistance with California insurance appeals, contact the DMHC Help Center at 888-466-2219.

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