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

How to Get HyperHEP (Hepatitis B Immune Globulin) Covered by Aetna CVS Health in Ohio: Prior Authorization Guide and Appeal Process

Quick Answer: Getting HyperHEP Covered by Aetna CVS Health in Ohio

HyperHEP (hepatitis B immune globulin) requires prior authorization from Aetna Better Health of Ohio for post-exposure prophylaxis. Submit via provider portal with exposure documentation, anti-HBs titer <10 mIU/mL, and CDC-compliant timing (within 24 hours ideally). Routine review takes 10 calendar days; urgent cases get 48-hour decisions. If denied, Ohio residents have 180 days to request external review through the Ohio Department of Insurance.

First step today: Have your provider check the Aetna Better Health Ohio PA portal for current HyperHEP requirements and submit with complete exposure details.

Table of Contents

  1. Understanding HyperHEP Coverage Requirements
  2. Prior Authorization Process for Aetna CVS Health
  3. Building Your Medical Necessity Case
  4. Common Denial Reasons and Solutions
  5. Ohio Appeals Process: Internal and External
  6. Emergency Coverage and Bridge Options
  7. Patient Scripts and Provider Resources
  8. FAQ: HyperHEP Coverage in Ohio

Understanding HyperHEP Coverage Requirements

HyperHEP (hepatitis B immune globulin) by Grifols provides immediate passive protection after hepatitis B exposure. For Aetna CVS Health members in Ohio, this medication typically falls under the medical benefit rather than pharmacy coverage since it's administered by injection.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for most plans Aetna Better Health Ohio PA Portal Aetna Ohio
Formulary Status Check current tier placement Aetna member portal or 2026 formulary list Plan documents
HCPCS Codes J0561 (≤7500 units), J0562 (>7500 units) FDA labeling and billing guides HyperHEP prescribing info
Timing Requirements Within 24 hours of exposure (ideally) CDC post-exposure guidelines Clinical protocols
Appeals Deadline 180 days for external review Ohio Department of Insurance Ohio appeals process

Prior Authorization Process for Aetna CVS Health

Step-by-Step: Fastest Path to Approval

  1. Verify Member Eligibility
    • Provider checks Aetna portal for current coverage
    • Confirm HyperHEP PA requirement using search tool
    • Timeline: Immediate
  2. Document the Exposure Event
    • Record exposure type (needlestick, sexual, perinatal)
    • Confirm source patient HBsAg-positive status
    • Timeline: Within hours of exposure
  3. Check Patient Susceptibility
    • Order anti-HBs titer if unknown
    • Document vaccination history
    • Timeline: Same day if urgent
  4. Submit PA Request
    • Use medical authorization form
    • Include exposure details and lab results
    • Submit via portal (preferred) or fax 1-855-734-9389
    • Timeline: ASAP after exposure
  5. Track Decision
    • Routine review: 10 calendar days
    • Urgent review: 48 hours
    • Call 1-855-364-0974 for status updates
  6. Appeal if Denied
    • Request internal appeal within plan timeframes
    • Gather additional clinical evidence
    • Timeline: Varies by plan type
  7. External Review (if needed)
    • File with Ohio Department of Insurance
    • 180-day deadline from final denial
    • Timeline: 30 days standard, 72 hours expedited
Tip: For emergency post-exposure situations, providers can administer HyperHEP and submit a retroactive PA. Emergency services are typically exempt from prior authorization delays.

Building Your Medical Necessity Case

Clinician Corner: Medical Necessity Letter Checklist

When submitting a prior authorization or appeal for HyperHEP, include these key elements:

Clinical Problem:

  • Documented hepatitis B exposure (percutaneous, mucosal, sexual)
  • Source patient confirmed HBsAg-positive
  • Patient susceptible (anti-HBs <10 mIU/mL or unvaccinated)

Treatment Rationale:

  • CDC guidelines support HBIG within 24 hours for high-risk exposures
  • Prevents chronic hepatitis B infection (up to 90% risk in exposed infants)
  • No contraindications to immune globulin therapy

Supporting Evidence:

  • FDA labeling for HyperHEP
  • CDC hepatitis B post-exposure prophylaxis guidelines
  • Patient's anti-HBs titer results
  • Documentation of exposure timing and circumstances

Dosing and Administration:

  • Standard dose: 0.06 mL/kg IM
  • Administered within recommended timeframe
  • Plan for concurrent hepatitis B vaccination

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
"Outside exposure window" Provide CDC guidance showing efficacy up to 7 days Exposure timeline, clinical notes
"Vaccination status unclear" Submit complete immunization records Vaccine history, titer results
"Not medically necessary" Emphasize prevention of chronic infection Source patient HBsAg results
"Quantity/dose exceeded" Reference FDA labeling for weight-based dosing Patient weight, dosing calculations
"Non-formulary drug" Request formulary exception with clinical justification Medical necessity letter

Counterforce Health: Streamlining Your Appeal

Counterforce Health helps patients and providers navigate complex prior authorization and appeal processes. Their platform analyzes denial letters, identifies specific payer criteria, and generates evidence-based appeals that address each denial reason point-by-point. For time-sensitive treatments like HyperHEP, having expert support can make the difference between a successful appeal and ongoing delays.

Ohio Appeals Process: Internal and External

Internal Appeals with Aetna CVS Health

Standard Timeline:

  • Submit appeal within plan-specified timeframe
  • Decision within 30-45 days for standard appeals
  • Expedited appeals: 72 hours for urgent medical situations

Required Documents:

  • Copy of denial letter
  • Updated medical records
  • Prescriber's clinical justification
  • Any new lab results or imaging

Ohio External Review Process

Ohio residents have strong appeal rights through the Ohio Department of Insurance external review process.

Key Features:

  • Free process - no cost to patients
  • 180-day deadline from final internal denial
  • Independent Review Organizations (IROs) with medical experts
  • Binding decisions on insurers when appeals are approved

Timeline:

  • Standard external review: 30 days
  • Expedited review: 72 hours for urgent cases
  • Submit additional information within 10 business days of IRO assignment

Contact Information:

Emergency Coverage and Bridge Options

When Time is Critical

For hepatitis B exposures requiring immediate treatment:

  1. Emergency Department Coverage
    • Most plans cover emergency HBIG administration
    • Submit retroactive PA within 24-48 hours
    • Document medical emergency in clinical notes
  2. Urgent Care Options
    • Verify in-network urgent care centers that stock HBIG
    • Call Aetna provider services to confirm coverage
    • Consider hospital outpatient departments for complex cases
  3. Bridge Therapy Considerations
    • HyperHEP provides protection for approximately 2 months
    • Coordinate with hepatitis B vaccination series
    • Monitor anti-HBs levels 1-2 months post-administration
Note: Emergency post-exposure prophylaxis typically bypasses prior authorization requirements, but providers should still submit documentation promptly to ensure reimbursement.

Patient Scripts and Provider Resources

Patient Phone Script for Aetna Member Services

"Hi, I'm calling about prior authorization for HyperHEP, a hepatitis B immune globulin my doctor prescribed after an exposure. My member ID is [number]. Can you tell me the current PA requirements and help me check if my provider has submitted the request? This is time-sensitive for post-exposure prophylaxis."

Key information to have ready:

  • Member ID and group number
  • Prescriber's name and NPI
  • HCPCS code J0561 or J0562
  • Date of exposure and clinical urgency

Provider Peer-to-Peer Request Script

"I'm requesting a peer-to-peer review for HyperHEP authorization for post-hepatitis B exposure prophylaxis. The patient had documented exposure to an HBsAg-positive source, is susceptible with anti-HBs <10 mIU/mL, and needs treatment within the CDC-recommended timeframe. Can we schedule this review today given the time-sensitive nature?"

FAQ: HyperHEP Coverage in Ohio

How long does Aetna CVS Health prior authorization take in Ohio? Routine PA decisions take up to 10 calendar days for Aetna Better Health of Ohio. Urgent requests receive decisions within 48 hours. Call 1-855-364-0974 for status updates.

What if HyperHEP is non-formulary on my plan? Request a formulary exception through Aetna Member Services at 1-844-362-0934. Decisions are made within 72 hours (24 hours if expedited). Your prescriber must provide a supporting statement explaining medical necessity.

Can I request an expedited appeal for HyperHEP denial? Yes, if the delay would seriously jeopardize your health. Aetna processes expedited appeals within 72 hours. Ohio external reviews can also be expedited within 72 hours for urgent medical situations.

Does step therapy apply to hepatitis B immune globulin? Step therapy rarely applies to time-sensitive post-exposure prophylaxis. However, some plans may require documentation that hepatitis B vaccination alone is insufficient for the clinical situation.

What if I have an employer self-funded plan? Self-funded ERISA plans follow federal rather than Ohio state appeal rules, but many voluntarily use similar external review processes. Check your plan documents or call the member services number on your insurance card.

How much does HyperHEP cost without insurance? Retail cash prices range from approximately $129-$900+ per vial depending on strength and pharmacy. Counterforce Health can help identify manufacturer assistance programs and foundation grants that may reduce out-of-pocket costs.

From Our Advocates

"We've seen many HyperHEP approvals succeed when providers emphasize the narrow window for effectiveness and include complete exposure documentation. The key is painting a clear picture of why immediate treatment prevents a much more serious chronic condition. One case involved a healthcare worker with a needlestick injury - the appeal succeeded when we highlighted CDC guidelines and included the source patient's confirmed HBsAg-positive status."

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and may change. Always verify current requirements with your insurance provider and consult healthcare professionals for medical decisions. For personalized assistance with insurance appeals, contact the Ohio Department of Insurance at 1-800-686-1526.

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