By Counterforce Health Team in Humira (adalimumab) —

How to Get Humira (adalimumab) Covered by Aetna CVS Health in Virginia: Appeals Guide with Forms & Timelines

Quick Answer: To get Humira (adalimumab) covered by Aetna CVS Health in Virginia, you'll likely need prior authorization with documented step therapy failures. If denied, file an internal appeal within 60 days, request a peer-to-peer review, then pursue Virginia's external review process through the State Corporation Commission. Start by calling Aetna at 1-866-638-1232 to confirm your plan's specific requirements.

Table of Contents

Understanding Your Aetna CVS Health Coverage

Aetna CVS Health typically requires prior authorization for Humira (adalimumab) and often mandates step therapy with preferred biosimilars first. In 2024, many Aetna plans have moved Humira to non-preferred tiers, favoring lower-cost adalimumab biosimilars like Amjevita or Cyltezo.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Must get approval before filling CVS Caremark PA Portal
Step Therapy Try preferred alternatives first Plan formulary document
Specialty Pharmacy Must use CVS Specialty Member portal or ID card
TB/Hepatitis Screening Required before approval FDA prescribing information
Specialist Requirement Rheumatologist, dermatologist, or GI Aetna provider directory

Prior Authorization Requirements

Aetna CVS Health's prior authorization criteria for Humira typically include:

Clinical Requirements:

  • FDA-approved diagnosis (rheumatoid arthritis, Crohn's disease, psoriasis, etc.)
  • Age-appropriate indication (varies by condition)
  • Prescription from or consultation with relevant specialist
  • Documented failure or intolerance to preferred agents

Safety Screening:

  • Negative tuberculosis screening (PPD or IGRA)
  • Hepatitis B testing (HBsAg, anti-HBc, anti-HBs)
  • Complete blood count and liver function tests

Step Therapy Documentation:

  • Trial and inadequate response to methotrexate (for RA/PsA)
  • Failure of preferred TNF inhibitor or adalimumab biosimilar
  • Documentation of contraindications or intolerances
Tip: Submit your PA request electronically through the CVS Caremark ePA system for faster processing.

Reading Your Denial Letter

When Aetna denies Humira coverage, your denial letter will contain critical information:

Key Elements to Identify:

  1. Denial reason code (step therapy, non-formulary, medical necessity)
  2. Appeal deadline (typically 60 days from denial date)
  3. Required documentation for appeals
  4. Preferred alternatives your plan covers
  5. Appeal submission methods (online portal, fax, mail)

Common Denial Reasons & Solutions:

Denial Reason How to Address
Step therapy not met Document trials/failures of preferred agents
Missing screening Submit TB/hepatitis B test results
Non-formulary Request formulary exception with medical necessity
Quantity limits exceeded Provide dosing rationale from specialist
Not medically necessary Submit comprehensive clinical documentation

First-Level Appeal Strategy

Your internal appeal is your strongest opportunity to overturn the denial. Aetna must respond within 30 days for standard appeals, 72 hours for urgent cases.

Step-by-Step Appeal Process

  1. Gather Documentation
    • Original denial letter
    • Complete medical records
    • Lab results (TB screening, CBC, LFTs)
    • Prior medication trial records
    • Specialist consultation notes
  2. Write Your Medical Necessity Letter
    • Address specific denial reasons
    • Document disease severity and impact
    • List failed prior therapies with dates and outcomes
    • Cite clinical guidelines supporting Humira use
    • Include safety screening results
  3. Submit Your Appeal
    • Online: Aetna member portal
    • Fax: 1-877-309-8077
    • Phone: 1-866-638-1232
    • Keep copies of everything submitted
From our advocates: We've seen the strongest appeals combine a detailed timeline of failed treatments with specific functional limitations (like inability to work or perform daily activities) that improved once the patient accessed adalimumab through samples or temporary coverage. Quantifying improvement helps reviewers understand medical necessity.

Peer-to-Peer Review Process

If your initial appeal is denied, request a peer-to-peer review where your doctor can speak directly with an Aetna medical director.

How to Request:

  • Call Aetna Provider Services at 1-866-638-1232
  • Submit written request with appeal form
  • Specify "peer-to-peer review requested"

Preparation Checklist:

  • Review patient's complete treatment history
  • Prepare 3-5 key talking points about medical necessity
  • Have clinical guidelines and studies ready to reference
  • Document contraindications to preferred alternatives

The peer-to-peer conversation typically lasts 10-15 minutes and can result in immediate approval if compelling clinical evidence is presented.

Virginia External Review Rights

Virginia residents have strong external review rights through the State Corporation Commission Bureau of Insurance. This independent review is binding on Aetna and free to patients.

When You Can Request External Review

  • After completing Aetna's internal appeals process
  • Denial based on medical necessity, experimental treatment, or similar clinical judgment
  • Within 120 days of final internal denial
  • Disputed amount exceeds $500

How to File

  1. Contact the Bureau First
    • Phone: 1-877-310-6560
    • Get guidance on Form 216-A completion
    • Confirm your case meets eligibility criteria
  2. Submit Required Documents
    • Completed Form 216-A (External Review Request)
    • Copy of final denial letter
    • All medical records supporting your case
    • Authorized representative form (if applicable)
  3. Timeline Expectations
    • Standard review: 45 days
    • Expedited review: 72 hours (if delay could jeopardize health)
    • Decision is final and binding on Aetna

Virginia's external review process has helped many patients access necessary specialty medications, including TNF inhibitors like Humira.

Appeal Letter Templates

Medical Necessity Letter Template

[Date]
Aetna Prior Authorization Department
[Fax: 1-877-309-8077]

RE: [Patient Name], DOB: [Date], Member ID: [Number]
Request for Coverage of Adalimumab (Humira)

Dear Medical Director,

I am writing to appeal the denial of adalimumab (Humira) for my patient [Name], who has [diagnosis] with [specific symptoms/complications].

CLINICAL HISTORY:
[Patient] was diagnosed with [condition] on [date]. Despite treatment with [list prior medications with dates and outcomes], the patient continues to experience [specific symptoms and functional limitations].

PRIOR THERAPY FAILURES:
- [Medication 1]: Trial from [date] to [date]. Discontinued due to [inadequate response/adverse effects]
- [Medication 2]: Trial from [date] to [date]. [Outcome and reason for discontinuation]

SAFETY SCREENING COMPLETED:
- Tuberculosis screening: [Test type] performed [date] with [result]
- Hepatitis B panel: Performed [date], negative for active infection
- Baseline laboratory studies within normal limits

MEDICAL NECESSITY JUSTIFICATION:
Adalimumab is medically necessary for this patient because [specific clinical rationale]. The FDA-approved indication for [condition] supports this use, and clinical guidelines from [organization] recommend TNF inhibitor therapy for patients who have failed [prior treatments].

I respectfully request approval of adalimumab for this patient and am available for peer-to-peer discussion at [phone number].

Sincerely,
[Provider Name, MD]
[Specialty]
[NPI Number]

Patient Phone Script

"Hi, I'm calling about a prior authorization denial for Humira. My member ID is [number]. I'd like to understand the specific reasons for denial and start the appeal process. Can you transfer me to someone who can help with appeals and tell me exactly what documentation you need?"

Tracking Your Appeal

Keep detailed records of your appeal process:

Appeal Log Template:

  • Date submitted: ___________
  • Method (fax/online/mail): ___________
  • Confirmation number: ___________
  • Expected decision date: ___________
  • Follow-up call scheduled: ___________
  • Decision received: ___________
  • Next steps: ___________

Important Deadlines:

  • Internal appeal response: 30 days (standard), 72 hours (urgent)
  • External review request: 120 days from final denial
  • External review decision: 45 days (standard), 72 hours (expedited)

Cost-Saving Options

While appealing, explore these cost-reduction strategies:

Manufacturer Support:

  • AbbVie Humira Complete savings program
  • Eligible patients may pay as little as $5 per month
  • Income and insurance type restrictions apply

Alternative Options:

  • Adalimumab biosimilars (often preferred by Aetna)
  • Patient assistance programs from biosimilar manufacturers
  • State pharmacy assistance programs in Virginia

Counterforce Health helps patients navigate these complex approval processes by analyzing denial letters, identifying the specific reasons for rejection, and drafting targeted appeals that address payer requirements point-by-point. Their platform pulls the right clinical evidence and weaves it into appeals that meet procedural requirements while tracking deadlines and required documentation.

When to Escalate

Contact Virginia regulators if you experience:

  • Missed appeal deadlines by Aetna
  • Inadequate review of medical evidence
  • Procedural violations in the appeal process

Virginia State Corporation Commission Bureau of Insurance:

  • Phone: 1-877-310-6560
  • Website: scc.virginia.gov
  • File complaints about insurance practices
  • Request assistance with external review process

Virginia Managed Care Ombudsman:

Frequently Asked Questions

Q: How long does Aetna prior authorization take for Humira? A: Standard PA decisions are made within 72 hours for urgent requests, 15 days for non-urgent. Appeals take 30 days for standard, 72 hours for expedited.

Q: What if Humira isn't on my Aetna formulary? A: Request a formulary exception by demonstrating medical necessity and documenting failures of preferred alternatives.

Q: Can I get expedited review if my condition is worsening? A: Yes, if your doctor certifies that delay could seriously jeopardize your health, request expedited appeal processing.

Q: Do I need to try biosimilars before Humira? A: Most Aetna plans require step therapy with preferred adalimumab biosimilars unless contraindicated or previously failed.

Q: What happens if external review denies coverage? A: The decision is final and binding. Consider consulting with a healthcare attorney or exploring alternative treatments.

Q: Does Virginia have any special protections for specialty drug appeals? A: Virginia allows expedited external review for cancer treatments without exhausting internal appeals and provides free advocacy through the Managed Care Ombudsman.

Sources & Further Reading

For additional support navigating the appeals process, Counterforce Health provides specialized assistance in turning insurance denials into successful appeals through evidence-based strategies tailored to specific payer requirements.

This guide is for informational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and contact Virginia insurance regulators for official guidance on appeals processes.

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