By Counterforce Health Team in HyperHEP (hepatitis B immune globulin) —

How to Get HyperHEP (Hepatitis B Immune Globulin) Covered by Aetna CVS Health in New York: Forms, Appeals & Timelines

Answer Box: Getting HyperHEP Covered by Aetna CVS Health in New York

HyperHEP (hepatitis B immune globulin) is typically covered by Aetna CVS Health under medical benefits for CDC-approved post-exposure prophylaxis scenarios. Key steps: 1) Verify your exposure meets Aetna's medical necessity criteria (needlestick, sexual contact with HBsAg-positive person, newborn to infected mother). 2) Provider submits precertification via Availity portal with exposure documentation. 3) If denied, file internal appeal within 60 days, then external appeal with NY DFS within 4 months. New York residents can get free help at 888-614-5400 (Community Health Advocates).

Table of Contents

  1. How to Use This Guide
  2. Eligibility Triage: Do You Qualify?
  3. If Likely Eligible: Document Checklist & Submission
  4. If Possibly Eligible: Tests to Request
  5. If Not Yet Eligible: Alternatives to Discuss
  6. If Denied: New York Appeal Path
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & How to Fix Them
  9. FAQ
  10. Sources & Further Reading

How to Use This Guide

This decision tree helps patients and clinicians navigate HyperHEP coverage with Aetna CVS Health in New York. HyperHEP is a hepatitis B immune globulin that provides immediate passive immunity after high-risk exposures. Unlike pharmacy benefits with formulary tiers, HyperHEP is covered under Aetna's medical benefit when medically necessary.

Start with the eligibility triage below. If you've already been denied, jump to the appeal section.

Note: This guide covers post-exposure prophylaxis scenarios. For chronic hepatitis B treatment, different coverage rules apply.

Eligibility Triage: Do You Qualify?

✅ Likely Eligible (Strong Medical Necessity)

You probably qualify for HyperHEP coverage if you have:

  • Percutaneous or mucosal exposure to HBsAg-positive blood (needlestick, splash to eyes/mouth)
  • Sexual contact with someone who has hepatitis B
  • Newborn whose mother is HBsAg-positive or unknown status
  • Household exposure (infant under 1 year with acute HBV-infected caregiver)
  • Documented unvaccinated or vaccine non-responder status

These scenarios align with Aetna's medical necessity policy and CDC guidelines.

⚠️ Possibly Eligible (Need More Documentation)

You might qualify but need additional testing or documentation:

  • Unknown vaccination status (need antibody testing)
  • Exposure to person with unknown HBsAg status (source testing needed)
  • Delayed presentation (beyond 48-72 hours post-exposure)
  • Incomplete exposure details (need incident report, medical records)

❌ Not Yet Eligible

Coverage is unlikely without additional justification:

  • Routine prevention without specific exposure
  • Exposure to HBsAg-negative source (if you're unvaccinated, vaccine alone is appropriate)
  • Already immune (anti-HBs ≥10 mIU/mL from prior vaccination)

If Likely Eligible: Document Checklist & Submission

Required Documentation

For Healthcare Providers:

  • Exposure incident report with date, time, and nature of contact
  • Source patient HBsAg status (positive or unknown)
  • Patient's hepatitis B vaccination history and antibody levels
  • Medical necessity letter citing CDC guidelines and Aetna policy
  • ICD-10 codes (Z87.891 for personal history of nicotine dependence, Z20.5 for contact with hepatitis)

For Patients:

  • Insurance card and member ID
  • Incident documentation (workplace report, medical records)
  • Vaccination records or antibody test results
  • Provider's treatment plan including timing and dosing

Submission Process

  1. Provider submits precertification via Aetna's Availity portal or fax (888) 267-3277
  2. Include Statement of Medical Necessity using Aetna's IVIG precert form as template
  3. Timeline: Submit at least 2 weeks in advance when possible; Aetna approves >95% of eligible PAs within 24 hours
Tip: For urgent post-exposure situations, administer HyperHEP immediately and submit retrospective authorization. Emergency treatment is typically covered pending review.

If Possibly Eligible: Tests to Request

Additional Testing Needed

For Unknown Vaccination Status:

  • Anti-HBs antibody test to determine immunity level
  • HBsAg and anti-HBc if exposure was significant

For Source Patient:

  • HBsAg testing if status unknown (coordinate with infection control)
  • HBV DNA if chronic infection suspected

For Delayed Presentation:

  • Baseline HBsAg, anti-HBs, anti-HBc before treatment
  • Follow-up testing plan at 1-2 months post-vaccination

Timeline to Re-apply

  • Complete testing within 1-2 weeks of exposure when possible
  • Resubmit PA request with complete documentation
  • Consider expedited review if still within optimal treatment window

If Not Yet Eligible: Alternatives to Discuss

Coverage Alternatives

Instead of HyperHEP:

  • Hepatitis B vaccine series alone (for low-risk exposures)
  • Combination therapy (vaccine + HBIG) per CDC guidelines
  • Alternative HBIG products if HyperHEP specifically excluded

Exception Request Strategies:

  • Off-label use documentation with medical literature support
  • Compassionate use appeal with clinical justification
  • Step therapy exception if alternatives contraindicated

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by identifying the specific denial basis and crafting point-by-point rebuttals aligned to each plan's own rules.

If Denied: New York Appeal Path

Level 1: Internal Appeal (Required First Step)

Timeline: File within 60 days of denial notice Process:

  1. Call Aetna member services (number on insurance card) to initiate
  2. Submit written appeal with denial letter and supporting documentation
  3. Request peer-to-peer review if clinical disagreement
  4. Decision timeline: 30 days standard, 72 hours for urgent

Required Documents:

  • Original denial letter
  • Medical necessity letter from provider
  • CDC guidelines supporting treatment timing
  • Exposure documentation

Level 2: New York External Appeal (After Internal Denial)

Timeline: File within 4 months of final internal denial Process:

  1. Complete NY External Appeal Application (download form)
  2. Mail to: NY Department of Financial Services, 99 Washington Ave, Box 177, Albany, NY 12210
  3. Independent medical review by certified external agent
  4. Decision is binding on Aetna if overturned

Get Free Help:

  • Community Health Advocates: 888-614-5400
  • Search past appeals at CHA's database

Expedited Appeals (Urgent Situations)

For post-exposure prophylaxis within critical timeframe:

  • Request expedited internal appeal: 72-hour decision
  • Simultaneous external appeal: Available for urgent medical needs
  • Contact NY DFS directly: 1-800-400-8882

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Precertification Required Provider must get approval before treatment Aetna Precert List Aetna
Medical Necessity Must meet CDC post-exposure criteria Policy 0544 Aetna
Timing Requirements Within 7 days of exposure preferred CDC Guidelines CDC
Administration Site Hospital, clinic, or provider office Member benefits summary Plan documents
Appeal Deadline 60 days internal, 4 months external NY DFS Appeals NY State

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Documents Needed
"Not medically necessary" Cite Aetna policy 0544 and CDC guidelines Medical necessity letter, exposure report
"Timing outside window" Document urgent medical need, cite studies on delayed treatment Literature showing efficacy beyond 7 days
"Vaccination status unclear" Provide antibody test results Anti-HBs levels, vaccination records
"Source patient status unknown" Explain inability to test source, justify prophylaxis Incident report, infection control consultation
"Experimental/investigational" Reference FDA approval and standard of care FDA labeling, medical society guidelines

Clinician Corner: Medical Necessity Letter Checklist

When writing support letters for HyperHEP coverage:

Essential Elements:

  • Specific exposure details (date, mechanism, source status)
  • Patient's vaccination/immunity status with lab values
  • Clinical rationale citing CDC post-exposure guidelines
  • Timing justification for immediate treatment need
  • Alternative therapies considered and why HBIG is preferred

Key Citations:

FAQ

Q: How long does Aetna CVS Health prior authorization take for HyperHEP in New York? A: Aetna approves >95% of eligible requests within 24 hours when submitted electronically. Emergency situations can be processed immediately with retrospective authorization.

Q: What if HyperHEP is non-formulary on my plan? A: HyperHEP is covered under medical benefits, not pharmacy formulary. Non-formulary status doesn't apply to medical benefit drugs like immune globulins.

Q: Can I request an expedited appeal if denied? A: Yes, for urgent post-exposure prophylaxis you can request expedited internal appeal (72-hour decision) and simultaneous external appeal through NY DFS.

Q: Does step therapy apply to HyperHEP? A: No step therapy requirements are indicated for HyperHEP. Post-exposure prophylaxis is time-sensitive and doesn't require trying other treatments first.

Q: What if I was exposed outside New York but have Aetna coverage here? A: New York appeal rights apply to your coverage regardless of where the exposure occurred. The same timeline and process apply.

Q: How much does HyperHEP cost without insurance? A: Retail prices range from approximately $129-$900+ per vial depending on strength and administration site. Contact Grifols patient assistance program for potential support.

From our advocates: "We've seen several hepatitis B exposure cases where initial denials were overturned by providing detailed exposure documentation and citing the specific CDC timing guidelines. The key is showing that the exposure meets the plan's own medical necessity criteria—not just that treatment is clinically appropriate. Having the incident report and source patient testing (when available) makes a significant difference in approval rates."

For complex denials involving medical necessity determinations, Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals that identify the specific denial basis and craft point-by-point rebuttals.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms, medical circumstances, and current policies. Always consult with your healthcare provider and insurance plan for specific coverage questions. For personalized assistance with insurance appeals in New York, contact Community Health Advocates at 888-614-5400.

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