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

How to Get HyperHEP (Hepatitis B Immune Globulin) Covered by Aetna CVS Health in Washington: PA Forms, Appeals, and Approval Scripts

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

Aetna CVS Health requires prior authorization for HyperHEP (hepatitis B immune globulin) in Washington, but approval is straightforward with proper documentation of post-exposure prophylaxis needs. The fastest path: (1) Have your provider call 1-866-752-7021 for expedited PA within 24-72 hours of exposure, (2) Submit complete exposure documentation and vaccination history, (3) If denied, file internal appeal within 180 days citing CDC guidelines. Washington's external review process through certified IROs provides binding decisions if internal appeals fail.

First step today: Contact your prescribing provider to initiate the PA request with documented exposure details and timing.

Table of Contents

  1. Plan Types & Coverage Implications
  2. Formulary Status & Tier Placement
  3. Prior Authorization & Step Therapy Requirements
  4. Specialty Pharmacy Requirements
  5. Cost-Share Basics
  6. Submission Process & Forms
  7. Common Approval Patterns
  8. Washington Appeals Process
  9. Scripts & Templates
  10. FAQ

Plan Types & Coverage Implications

Aetna CVS Health offers several plan types in Washington, each with different coverage rules for HyperHEP:

HMO Plans: Require referrals from your primary care physician before accessing specialty care. For post-exposure prophylaxis, emergency departments can typically prescribe HyperHEP without prior referral, but follow-up doses may need PCP coordination.

PPO Plans: Allow direct access to specialists and emergency care without referrals. Most common for employer-sponsored coverage in Washington.

EPO Plans: Network-only coverage without referrals. Emergency care for hepatitis B exposure is covered regardless of network status.

Medicaid (Apple Health): Washington's expanded Medicaid program covers HyperHEP with different PA requirements through managed care organizations contracted with Aetna.

Note: Self-funded employer plans follow federal ERISA rules rather than Washington state insurance laws, affecting your appeal rights.

Formulary Status & Tier Placement

HyperHEP typically appears on Aetna formularies as a non-preferred specialty product requiring prior authorization. According to Aetna's formulary documents, hepatitis B immune globulin products are marked "PA" (prior authorization required).

Alternative Agents:

  • Other HBIG brands (HepaGam B, Nabi-HB)
  • Hepatitis B vaccine series (preferred for prevention, not post-exposure)
  • Combined HBIG + vaccine protocols per CDC guidelines

Formulary Verification: Check your specific plan's drug list at Aetna's member portal or call member services. Formulary tiers can change annually.

Prior Authorization & Step Therapy Requirements

PA Requirements

Aetna requires prior authorization for all hepatitis B immune globulin products. According to Aetna's clinical policy, HBIG is considered medically necessary for:

  • Post-exposure prophylaxis in susceptible individuals
  • Perinatal prophylaxis for infants of HBsAg-positive mothers
  • Prevention of hepatitis B recurrence after liver transplantation
  • Household or sexual contacts of acute hepatitis B cases

Step Therapy Considerations

Aetna typically requires documentation of vaccination status before approving HBIG. Step therapy does not apply if you've received HBIG in the past 365 days or if immediate post-exposure prophylaxis is needed.

Required Documentation:

  • Hepatitis B vaccination history
  • Anti-HBs antibody levels (if available)
  • Details of exposure incident
  • Timing of exposure and treatment request

Medical Necessity Criteria

Coverage requires exposure within the CDC-recommended window (ideally within 24 hours, up to 7 days post-exposure) and documentation that the patient is susceptible to hepatitis B infection.

Specialty Pharmacy Requirements

Aetna routes most HyperHEP prescriptions through CVS Specialty Pharmacy. The process involves:

  1. Enrollment: Patients must enroll with CVS Specialty after PA approval
  2. Benefits Verification: CVS verifies coverage and coordinates delivery
  3. Clinical Support: CVS provides injection training and monitoring if needed

Contact Information:

  • CVS Specialty: 1-800-237-2767
  • Provider line: 1-866-814-5506

For emergency post-exposure prophylaxis, hospital pharmacies can typically dispense HyperHEP immediately while PA is processed retroactively.

Cost-Share Basics

Your out-of-pocket costs depend on your plan's structure:

Typical Cost-Sharing:

  • Deductible applies before coverage begins
  • Specialty tier copay or coinsurance (often 20-40% after deductible)
  • Out-of-network penalties if not using preferred providers

Cost-Saving Options:

  • Grifols patient assistance may offer copay support
  • Emergency/urgent care settings may have different cost-sharing rules
  • Appeal excessive cost-sharing through Aetna's exception process
Educational Note: These are general cost structures. Verify your specific benefits through Aetna member services at 1-800-872-3862.

Submission Process & Forms

Prior Authorization Submission

Provider Contact:

Required Information:

  • Patient demographics and insurance details
  • ICD-10 diagnosis code (Z87.19 for exposure history)
  • Detailed exposure documentation
  • Clinical justification citing CDC guidelines
  • Requested quantity and administration schedule

Statement of Medical Necessity

Aetna requires a completed Statement of Medical Necessity (SMN) including:

  • Nature and timing of hepatitis B exposure
  • Patient's vaccination status and antibody levels
  • Clinical rationale for HBIG vs. vaccination alone
  • Expected duration of treatment

Common Approval Patterns

Successful HyperHEP approvals typically include:

Strong Documentation:

  • Detailed exposure incident report
  • Clear timeline showing treatment within recommended window
  • Evidence of patient susceptibility (unvaccinated or inadequate antibody response)
  • Reference to CDC post-exposure prophylaxis guidelines

Clinical Justification:

  • Explanation why HBIG is preferred over vaccination alone
  • Weight-based dosing calculations
  • Monitoring plan for antibody response

Common Approval Timeline: 24-72 hours for urgent cases, 5-15 business days for standard requests.

Washington Appeals Process

If Aetna denies your HyperHEP request, Washington provides robust appeal protections:

Internal Appeals

Timeline: File within 180 days of denial notice Process: Submit written appeal with additional documentation Decision: 30 days for standard, 72 hours for expedited

External Review

Washington's independent review process provides binding decisions:

Eligibility: Available after final internal denial Timeline: Request within 60 days of final denial Process: Submit request to Aetna, who assigns certified IRO Decision: 20 days for fully-insured plans, binding on insurer

Washington Insurance Commissioner Support:

Scripts & Templates

Patient Phone Script for Aetna

"Hi, I need to check on prior authorization status for HyperHEP hepatitis B immune globulin. My member ID is [ID]. This is for post-exposure prophylaxis after [type of exposure] on [date]. My provider submitted the PA on [date]. Can you provide the status and any missing information needed?"

Provider Peer-to-Peer Request

"I'm requesting a peer-to-peer review for [patient name] who needs HyperHEP for post-exposure prophylaxis. The patient had documented exposure to hepatitis B on [date] and meets CDC criteria for immediate passive immunization. The timing is critical for efficacy. When can we schedule the clinical review?"

Medical Necessity Letter Template

"[Patient] requires HyperHEP (hepatitis B immune globulin) for post-exposure prophylaxis following [exposure type] on [date]. Per CDC guidelines, HBIG is indicated within 7 days of exposure for susceptible individuals. Patient's vaccination status: [details]. Anti-HBs levels: [if available]. Clinical rationale: [explanation]. Requested dose: [amount] based on patient weight of [weight]."

Counterforce Health: Streamlining Your Appeals Process

Getting complex medications like HyperHEP approved often requires navigating multiple appeal levels with precise documentation. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned to each payer's specific rules.

The platform pulls the right citations—FDA labeling, peer-reviewed studies, and specialty guidelines—and weaves them into appeals with required clinical facts like diagnosis codes, prior treatment failures, and dosing rationale. For medications like HyperHEP, this includes operational details payers expect such as site of care and administration timing.

FAQ

How long does Aetna CVS Health PA take in Washington? Expedited requests (urgent medical need) typically receive decisions within 24-72 hours. Standard requests take 5-15 business days. Post-exposure prophylaxis qualifies for expedited review.

What if HyperHEP is non-formulary on my plan? Request a formulary exception with clinical justification. Aetna must cover medically necessary treatments even if non-formulary, especially for post-exposure prophylaxis with no therapeutic alternatives.

Can I get HyperHEP at any pharmacy? Most plans require CVS Specialty Pharmacy for specialty medications. Emergency departments and hospitals can typically dispense immediately for urgent cases.

Does step therapy apply if I've failed hepatitis B vaccination? Document vaccination failure with anti-HBs antibody levels <10 mIU/mL. For post-exposure prophylaxis, step therapy typically doesn't apply due to timing requirements.

What's covered for perinatal hepatitis B prevention? Infants born to HBsAg-positive mothers typically receive both HBIG and hepatitis B vaccine within 12 hours of birth. This is usually covered without PA for emergency/urgent care.

How do I appeal if Aetna says the timing is too late? Cite clinical literature showing efficacy beyond 24 hours and emphasize that CDC guidelines allow up to 7 days post-exposure. Include detailed exposure timeline and any delays in seeking care.

Coverage at a Glance

Requirement What It Means Where to Find It Source
PA Required Prior authorization mandatory Formulary documents Aetna Formulary
Formulary Tier Non-preferred specialty Member portal Aetna Member Services
Step Therapy Vaccination history required Clinical policy Aetna Policy 0544
Quantity Limits Weight-based dosing FDA labeling HyperHEP Prescribing Info
Site of Care Specialty pharmacy preferred Benefit documents CVS Specialty
Appeals Deadline 180 days from denial Washington law OIC Appeals Guide
From Our Advocates: We've seen many hepatitis B exposure cases where initial denials were overturned simply by providing complete exposure documentation and emphasizing the time-sensitive nature of post-exposure prophylaxis. The key is demonstrating that the patient meets CDC criteria and that HBIG is being requested within the appropriate window. Aetna typically approves when the medical necessity is clearly established with proper timing documentation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements may change. Always verify current information with Aetna CVS Health and consult healthcare providers for medical decisions. For assistance with insurance appeals in Washington, contact the Office of the Insurance Commissioner at 1-800-562-6900.

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