By Counterforce Health Team in Humira (adalimumab) —

How to Get Humira (adalimumab) Covered by Aetna (CVS Health) in Pennsylvania: 2024 Forms, Appeals & Contact Guide

Answer Box: Getting Humira Covered by Aetna in Pennsylvania

Pennsylvania Aetna members need prior authorization for Humira (adalimumab), but benefit from the state's step therapy exemption for fully insured plans. Submit the Aetna precertification form with TB screening and prior therapy documentation. If denied, appeal within 60 days internally, then use Pennsylvania's Independent External Review Program within 4 months—which overturns 53% of denials. Start by calling Aetna at 1-866-638-1232 to verify your plan requirements.

Table of Contents

  1. Verify Your Plan & Coverage
  2. Prior Authorization Forms & Requirements
  3. Submission Portals & Methods
  4. CVS Specialty Pharmacy Transfer
  5. Appeals Process in Pennsylvania
  6. Contact Directory
  7. Cost Assistance Programs
  8. FAQ

Verify Your Plan & Coverage

Step 1: Confirm Your Aetna Plan Type

Before starting any paperwork, identify your specific Aetna plan. Pennsylvania residents may have:

  • Aetna Better Health Pennsylvania (Medicaid managed care)
  • Commercial Aetna plans through employers
  • ACA marketplace plans via Pennie
  • Medicare Advantage plans

Call the member services number on your insurance card to confirm your plan type and formulary tier for Humira.

Pennsylvania Step Therapy Advantage

Good news for Pennsylvania residents: Fully insured Aetna plans in Pennsylvania are exempt from step therapy requirements for adalimumab products, including Humira. This means you typically won't need to try biosimilar alternatives first, unlike members in other states.

However, prior authorization is still required, and your plan may prefer lower-cost biosimilars like Amjevita or Cyltezo on their formulary.

Prior Authorization Forms & Requirements

Required Documentation Checklist

✅ Aetna Precertification Form (download here)
✅ FDA-approved diagnosis with ICD-10 codes
✅ TB screening results (PPD test, interferon-gamma assay, or chest X-ray)
✅ Hepatitis B testing (HBsAg, anti-HBc, anti-HBs)
✅ Complete blood count and liver function tests
✅ Documentation of disease severity at baseline
✅ Prior therapy trials and failures (if applicable)

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all plans Aetna PA Guidelines
Step Therapy Exempt in PA (fully insured) Pennsylvania Insurance Code
Formulary Tier Often non-preferred (2024) Plan-specific formulary
Specialty Pharmacy CVS Specialty required Aetna policy
Age Limits Per FDA label by indication FDA prescribing information

Submission Portals & Methods

Electronic Submission (Fastest)

CVS Caremark ePA System - Recommended for quickest processing

  • Access through your EHR system or CVS provider portal
  • Standard decisions: 15 days (non-urgent), 72 hours (urgent)
  • Electronic submission reduces processing delays

Phone & Fax Options

Prior Authorization Contacts:

  • Phone: 1-855-240-0535
  • Fax: 1-877-269-9916 or 1-844-268-7263 (Medicare Part B)

Mail Submission:

Medical Exception to Pharmacy Prior Authorization Unit
1300 East Campbell Road
Richardson, TX 75081
Tip: Include a cover sheet with member ID, prescriber NPI, and "HUMIRA PRIOR AUTHORIZATION" clearly marked.

CVS Specialty Pharmacy Transfer

Since Aetna requires CVS Specialty for Humira dispensing, you'll need to transfer your prescription if it's currently at another pharmacy.

Transfer Process

  1. Online Transfer: Visit cvs.com and use the "Transfer Prescription" tool
  2. Phone Transfer: Call CVS Specialty with your current prescription label
  3. Provider Transfer: Your doctor can send the prescription directly to CVS Specialty

CVS Specialty Enrollment

  • Shipping: Home delivery included (≤10 days standard)
  • Refills: Managed through Aetna member portal
  • Payment: Ensure payment information is on file to avoid delays

Appeals Process in Pennsylvania

Pennsylvania offers one of the strongest patient appeal processes in the nation. Here's your roadmap if Humira is initially denied.

Step-by-Step Appeals Process

1. Internal Appeal (Required First Step)

  • Deadline: 60 days from denial notice
  • Method: Aetna member portal or written appeal
  • Timeline: 30 days for standard, 72 hours for urgent
  • Contact: 1-866-638-1232

2. Pennsylvania Independent External Review

  • Eligibility: After receiving "Final Adverse Benefit Determination"
  • Deadline: 4 months from final denial
  • Success Rate: 53% of appeals overturned in 2024
  • Submit: pa.gov/services/insurance

Pennsylvania External Review Timeline

Stage Timeline Action Required
Submission Day 1 Submit online form with denial letter
Eligibility Check 1-5 days PID confirms eligibility
IRO Assignment 1 day Independent reviewer assigned
Additional Evidence 15 days Submit supporting documents
Final Decision 45 days Binding decision issued

Required Appeal Documents

  • Final Adverse Benefit Determination letter
  • Insurance card copy
  • Medical records supporting medical necessity
  • Physician statement of clinical rationale
  • Lab results and imaging (if relevant)

Contact Directory

Aetna Member Services

  • General: 1-866-638-1232 (TTY: 711)
  • Prior Authorization: 1-855-240-0535
  • Appeals: Use member portal or mail to address above

CVS Caremark Pharmacy

  • Prior Authorization: 1-855-344-0930 (Medicare Part D)
  • Specialty Pharmacy: Contact via member portal
  • Fax: 1-855-633-7673

Pennsylvania Resources

  • Insurance Department: pa.gov/services/insurance
  • Consumer Assistance: Pennsylvania Health Law Project
  • External Review: Online submission portal at pa.gov

Cost Assistance Programs

AbbVie Humira Complete Program

  • Copay assistance: Up to $5 per month for eligible patients
  • Patient support: Injection training and adherence support
  • Eligibility: Commercial insurance required (not government plans)

Foundation Assistance

  • Patient Access Network Foundation
  • Good Days Foundation
  • HealthWell Foundation
Note: Verify current eligibility criteria as programs change annually.

Clinician Corner: Medical Necessity Letter

When appealing a Humira denial, include these elements in your medical necessity letter:

Essential Components:

  • Specific FDA-approved diagnosis with severity documentation
  • Previous treatment trials and clinical outcomes
  • Contraindications to preferred alternatives
  • Expected treatment goals and monitoring plan
  • Relevant clinical guidelines supporting use

Key Citations to Include:

  • FDA prescribing information for approved indications
  • ACR/EULAR guidelines for rheumatologic conditions
  • AGA guidelines for inflammatory bowel disease
  • AAD guidelines for dermatologic conditions

Frequently Asked Questions

Q: How long does Aetna prior authorization take in Pennsylvania? A: Standard requests: 15 days; urgent requests: 72 hours. Electronic submissions through CVS Caremark ePA are typically faster.

Q: What if Humira is non-formulary on my plan? A: Request a formulary exception with medical necessity documentation. Pennsylvania's step therapy exemption may help your case.

Q: Can I request an expedited appeal? A: Yes, if your condition poses immediate health risks. Your physician must complete a certification form confirming urgent medical need.

Q: Does my doctor need to try biosimilars first? A: Not in Pennsylvania for fully insured plans due to the state's step therapy exemption. Self-insured plans may still require step therapy.

Q: What happens if my external review is approved? A: Aetna must immediately provide coverage, including retroactive coverage if you paid out-of-pocket during the appeal.

Q: How much does Humira cost without insurance? A: List price is approximately $6,000-$7,000 per month. The AbbVie Humira Complete program may provide significant assistance.

When Coverage Gets Complicated

Sometimes getting Humira approved requires extra persistence. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies, then drafts point-by-point rebuttals aligned with your insurer's own rules, pulling the right citations and clinical documentation to strengthen your case.

If you're facing repeated denials or complex prior authorization requirements, specialized appeal assistance can make the difference between paying thousands out-of-pocket and getting your treatment covered.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage processes and should not be considered medical or legal advice. Coverage policies vary by plan and change frequently. Always verify current requirements with your insurance company and consult your healthcare provider about treatment decisions. For personalized assistance with complex appeals, consider consulting with patient advocacy organizations or specialized coverage support services.

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