By Counterforce Health Team in Humira (adalimumab) —

How to Get Humira (adalimumab) Covered by Aetna (CVS Health) in Washington: Complete Appeals Guide with State Protections

Quick Answer: Getting Humira (adalimumab) Approved by Aetna (CVS Health) in Washington

Most Aetna CVS Health plans in Washington require prior authorization for Humira (adalimumab) and often prefer biosimilars first. Your fastest path: 1) Download the Humira PA form for CVS Health (Aetna) specific to your plan, 2) Document any failed adalimumab biosimilars or medical reasons to avoid them, and 3) Submit with strong clinical justification. If denied, Washington residents have robust appeal rights including external review by independent specialists. Start today by calling Aetna member services to confirm your exact PA requirements.

Table of Contents

Why Washington State Rules Matter for Your Aetna Coverage

Washington has some of the strongest patient protections in the country, but they don't apply equally to all Aetna plans. If you have a fully insured commercial plan or coverage through Washington Healthplanfinder, you're protected by state laws that set strict timelines for decisions and guarantee access to independent review. However, if your employer has a self-funded ERISA plan (even if administered by Aetna), federal law generally preempts state protections.

The key difference: Washington's external review process under RCW 48.43.535 allows independent medical specialists to overturn Aetna's denials, and their decisions are binding on the insurer. This has proven especially effective for specialty medications where initial denials are common.

Note: Starting in 2025, Washington's new Specialist Care Access Act requires that appeals involving specialist care be reviewed by physicians in the same or related specialty, significantly improving approval rates for complex medications like Humira.

Prior Authorization Requirements and Timelines

Coverage at a Glance

Requirement What it means Where to find it Timeline
Prior Authorization Required for most Humira prescriptions CVS Health Aetna PA forms 5 business days (standard)
Step Therapy May require trying biosimilars first Plan-specific drug guide 3 business days for override
Medical Necessity Must document diagnosis and severity Prescriber letter required Reviewed with PA
TB/HBV Screening Required before TNF inhibitor therapy Lab results within 6 months Include with submission

Step-by-Step: Fastest Path to Approval

  1. Verify your exact plan type - Call Aetna member services at the number on your card to confirm if you have commercial, Medicare Advantage, or employer coverage, and whether it's fully insured or self-funded.
  2. Download the correct PA form - Visit the Humira CVS Health (Aetna) PA forms page and select your specific plan type and region.
  3. Gather required documentation - Collect diagnosis codes, prior treatment history, lab results (especially TB and hepatitis B screening), and current disease activity measures.
  4. Complete the clinical justification - Your prescriber should document the specific indication, disease severity, prior therapies tried and failed, and why Humira is medically necessary.
  5. Submit via the fastest method - Electronic PA through your EHR system or fax to the number listed on the PA form (typically 1-888-267-3277 for specialty drugs).
  6. Track your request - Standard decisions come within 5 business days; urgent requests within 72 hours under Washington law for fully insured plans.
  7. Prepare for potential step therapy - If Aetna requires trying a biosimilar first, document any clinical reasons why this would be inappropriate or harmful.

Step Therapy Protections and Medical Exceptions

Washington state law provides several pathways to override step therapy requirements, which is crucial since many Aetna plans now prefer adalimumab biosimilars over originator Humira.

When Step Therapy Override Must Be Granted

Under Washington's step therapy guardrails, Aetna must approve an exception when you document:

  • Previous failure or intolerance of the required step drug or a pharmacologically equivalent agent
  • Contraindication to the step drug based on your clinical characteristics
  • Lack of expected effectiveness based on predictive biomarkers or published evidence
  • Stability on current therapy where switching would likely cause destabilization
  • FDA indication mismatch where the step drug isn't approved for your specific condition

Documentation That Works

When requesting a step therapy override, include specific language like:

"Patient previously trialed adalimumab biosimilar [specific name] from [dates] with inadequate response despite 12 weeks of therapy at optimal dosing. DAS28 remained elevated at 5.2 with continued joint swelling and morning stiffness >2 hours. Given the risk of irreversible joint damage and the patient's young age, cycling to another TNF inhibitor is not clinically appropriate."

For patients stable on Humira who face a forced switch:

"Patient has maintained remission on adalimumab (Humira) for 18 months with DAS28 <2.6 and normal inflammatory markers. Non-medical switching to a biosimilar poses significant risk of disease flare and loss of established therapeutic relationship with this specific formulation."

Continuity of Care Rights

Washington provides strong continuity protections, especially important if you're already stable on Humira and your plan changes its formulary preferences.

If you're transitioning between plans or your current plan implements new step therapy requirements, you may be entitled to:

  • Temporary continuation of current therapy (typically 30-90 days) while appeals are processed
  • Grandfathering if you were stable on therapy before new restrictions took effect
  • Expedited review if interruption would pose serious health risks

For continuity requests, emphasize disease stability and the medical risks of interruption. The Washington Office of Insurance Commissioner can help clarify your specific rights at 1-800-562-6900.

External Review and State Complaint Process

Washington's external review process is one of your strongest tools if Aetna denies coverage for Humira.

When You Can Request External Review

After exhausting Aetna's internal appeals (typically 1-2 levels), you can request independent review if:

  • The denial involves medical necessity determinations
  • Coverage was terminated or reduced
  • You believe the denial was inappropriate or not evidence-based

How to File for External Review

  1. Request within the deadline - You have 120-180 days from Aetna's final internal denial (verify exact timeline with your plan documents)
  2. Contact the Washington OIC - Call 1-800-562-6900 or visit the OIC appeals section to initiate the process
  3. Submit comprehensive records - Include all denial letters, medical records, prescriber letters, treatment history, and supporting literature
  4. Request expedited review if urgent - Available within 72 hours if delay could seriously jeopardize your health

What Makes External Review Effective

The independent review organization (IRO) assigned by Washington includes medical specialists who can override Aetna's determination. They consider:

  • Medical necessity based on current standards of care
  • Appropriateness of the treatment for your specific condition
  • Whether Aetna's criteria are reasonable and evidence-based
From our advocates: We've seen Washington's external review process successfully overturn denials for specialty biologics in about 40% of cases, particularly when the initial denial relied on outdated criteria or failed to consider patient-specific factors that make standard alternatives inappropriate.

Practical Scripts and Sample Language

Phone Script for Calling Aetna Member Services

"I need to verify the prior authorization requirements for Humira, generic name adalimumab, for [your condition]. Can you tell me if this requires PA, what forms I need, and whether there are any step therapy requirements? I'm also requesting the specific clinical criteria your plan uses for approval decisions."

Peer-to-Peer Request Script for Clinicians

"I'm requesting a peer-to-peer review for my patient's Humira prior authorization. The patient has [condition] with documented severity and has failed [specific prior therapies]. I can provide detailed clinical notes and explain why biosimilar alternatives are not appropriate in this case."

Appeal Letter Opening

"I am writing to formally appeal the denial of coverage for adalimumab (Humira) for my patient [name], policy number [number]. The denial letter dated [date] cited [specific reason]. Based on the medical evidence outlined below and the patient's clinical history, this medication is medically necessary and should be covered under the plan's terms."

ERISA vs. Individual Market Differences

Understanding your plan type is crucial because it determines which protections apply:

Fully Insured Plans (Individual Market, Small Group)

  • Protected by Washington state law including external review rights
  • Binding IRO decisions when they overturn denials
  • State timeline requirements for PA and appeal decisions
  • Access to OIC consumer advocacy and complaint process

Self-Funded ERISA Plans (Large Employers)

  • Federal ERISA law governs instead of state protections
  • No automatic external review unless employer voluntarily provides it
  • Federal court appeals after exhausting plan appeals
  • Different timeline requirements based on plan documents

To determine your plan type, check with your HR department or call Aetna member services. If you have an ERISA plan, focus on building the strongest possible internal appeals and consider consulting an ERISA attorney if coverage is denied.

Cost Savings and Patient Assistance

Even with insurance approval, Humira can be expensive. Consider these options:

  • AbbVie Complete Humira - Manufacturer copay assistance and patient support program
  • Foundation assistance - Organizations like the HealthWell Foundation offer grants for eligible patients
  • Biosimilar alternatives - If medically appropriate, biosimilars may have lower out-of-pocket costs
  • Specialty pharmacy benefits - CVS Specialty may offer better pricing than retail pharmacies

Counterforce Health helps patients navigate insurance denials by creating targeted, evidence-backed appeals that address the specific reasons for denial and align with each plan's criteria. Their platform can be particularly valuable when dealing with complex prior authorization requirements or multiple denial reasons.

Quick Reference Guide

Key Contacts

  • Aetna Member Services: Number on your insurance card
  • CVS Caremark PA Department: 1-888-267-3277 (fax for specialty drugs)
  • Washington OIC Consumer Line: 1-800-562-6900
  • AbbVie Complete (Humira support): 1-800-4HUMIRA

Important Timelines (Washington Fully Insured Plans)

  • Standard PA decision: 5 business days
  • Urgent PA decision: 72 hours
  • Step therapy override: 3 business days
  • Internal appeal deadline: 180 days from denial
  • External review deadline: 120-180 days from final internal denial

Required Documentation

  • Current diagnosis with ICD-10 codes
  • Disease activity measures and severity documentation
  • Complete prior treatment history with dates and outcomes
  • TB and hepatitis B screening results
  • Prescriber letter of medical necessity

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take in Washington? Standard decisions take up to 5 business days for fully insured plans, with urgent requests decided within 72 hours under Washington law.

What if Humira is non-formulary on my Aetna plan? You can request a formulary exception by documenting medical necessity and why formulary alternatives are inappropriate. The process is similar to prior authorization.

Can I request an expedited appeal if my condition is worsening? Yes, Washington law requires expedited appeals within 72 hours when delay could seriously jeopardize your health. Document the urgency clearly in your request.

Does step therapy apply if I've been stable on Humira from another state? Washington has continuity protections, but the specific rules depend on your plan type. Contact the OIC at 1-800-562-6900 for guidance on your situation.

What happens if the external review upholds Aetna's denial? The IRO decision is final for the external review process, but you may still have options through state complaints or, for ERISA plans, federal court appeals.

How can I find out if my employer plan is self-funded or fully insured? Ask your HR department directly, or call Aetna member services. This information should also be in your Summary Plan Description (SPD).

Are there income limits for manufacturer assistance programs? Most programs have income guidelines, typically allowing households earning up to $100,000-$150,000 annually to qualify for some level of assistance.

Can I appeal if Aetna requires a specific biosimilar instead of Humira? Yes, you can request a medical exception to step therapy by documenting why the specific biosimilar is inappropriate or why you need to continue Humira.

For complex denials or multiple appeal attempts, platforms like Counterforce Health can help create comprehensive appeals that address payer-specific criteria and increase your chances of approval.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on your specific plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan for guidance specific to your situation. For questions about Washington insurance regulations, contact the Office of the Insurance Commissioner at 1-800-562-6900.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.