By Counterforce Health Team in Keytruda (pembrolizumab) —

How to Get Keytruda (Pembrolizumab) Covered by Aetna (CVS Health) in Washington: Complete Guide with Forms and Appeal Scripts

Answer Box: Getting Keytruda Covered by Aetna in Washington

Aetna (CVS Health) requires prior authorization for Keytruda (pembrolizumab) with biomarker documentation (PD-L1 CPS ≥1, MSI-H, or TMB-H ≥10). Submit via fax to 1-888-267-3277 with clinical notes, pathology, and prior therapy records. If denied, appeal within 180 days; Washington offers external review through certified Independent Review Organizations (IROs) with 68% overturn rates for oncology appeals. First step: Download Aetna's Keytruda precertification form and gather biomarker test results.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Keytruda prescriptions Submit via Aetna provider portal or fax 1-888-267-3277 Aetna PA Form
Biomarker Testing PD-L1 CPS ≥1, MSI-H/dMMR, or TMB-H ≥10 mut/Mb required CLIA-certified lab using FDA-approved assays (22C3 IHC) Aetna Clinical Policy
Specialty Pharmacy Must fill through CVS Specialty Pharmacy CVS Specialty network verification CVS Specialty Drug List
Step Therapy May require prior treatment failure documentation Varies by indication and line of therapy Aetna Clinical Policy
Appeals Deadline 180 days from final denial for internal appeals Washington state insurance law RCW 48.43.535
External Review Available after internal appeals exhausted Submit to Washington Office of Insurance Commissioner WA Insurance Commissioner

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient/Clinic)

Who: Your oncology team
Timeline: 1-2 weeks before treatment start
Documents needed:

  • Pathology report confirming diagnosis and stage
  • Biomarker test results (PD-L1 CPS, MSI-H, or TMB-H) from CLIA-certified lab
  • Prior treatment history with dates and outcomes
  • Current imaging showing disease status

2. Submit Prior Authorization Request (Clinic)

Who: Provider or office staff
How: Complete Aetna Keytruda PA form and fax to 1-888-267-3277
Timeline: Submit 7-10 days before planned treatment
Include: All clinical documentation, FDA indication citation, NCCN guideline reference

3. Track Decision (Patient/Clinic)

Timeline: 30-45 days for standard review, 72 hours for expedited
How to check: Call Aetna provider services or check online portal
If approved: Coordinate with CVS Specialty Pharmacy for drug delivery

4. Appeal if Denied (Patient/Clinic)

Timeline: Must appeal within 180 days of denial
First step: Request peer-to-peer review within 14 days
Documentation: Gather additional evidence, clinical studies, expert opinions

Clinician Corner: Medical Necessity Letter Checklist

When submitting your prior authorization or appeal, include these key elements in your medical necessity letter:

Problem Statement:

  • Patient diagnosis with ICD-10 code and stage
  • Current disease status and progression

Prior Treatments:

  • List all previous therapies with dates
  • Document treatment failures, progression, or intolerance
  • Include imaging dates showing progression

Clinical Rationale:

  • FDA-approved indication for patient's specific cancer type
  • Biomarker results supporting Keytruda use
  • NCCN guideline recommendation for line of therapy

Dosing & Monitoring:

  • Proposed regimen (200mg q3w or 400mg q6w)
  • Monitoring plan for efficacy and toxicity
  • Expected treatment duration

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Key Documents
Missing PD-L1 CPS score Submit lab report with 22C3 IHC results showing CPS ≥1 CLIA lab report, test methodology
Wrong line of therapy Document prior treatment failures with dates and imaging Treatment timeline, progression scans
Non-formulary status Request formulary exception with medical necessity FDA label, NCCN guidelines, contraindications to alternatives
Step therapy not met Prove alternatives failed or are contraindicated Prior authorization denials, allergy documentation
Experimental/investigational Cite FDA approval and established guidelines FDA label excerpt, peer-reviewed studies

Appeals Playbook for Washington

Internal Appeals with Aetna

Level 1 (Peer-to-Peer Review)

  • Timeline: Request within 14 days of denial
  • Process: Oncologist speaks directly with Aetna medical director
  • How to request: Call Aetna provider services

Level 2 (Formal Internal Appeal)

  • Timeline: 180 days from final denial
  • Process: Submit written appeal with additional evidence
  • Expected response: 30 days for standard, 72 hours for expedited

Washington State External Review

After exhausting Aetna's internal appeals, Washington residents can request an independent external review through a certified Independent Review Organization (IRO).

Eligibility: Available for all fully insured plans (not self-funded ERISA plans)
Timeline: Request within 180 days of final internal denial
Process: Submit request to Washington Office of Insurance Commissioner
Decision timeline: 30 days for standard review, 72 hours for expedited
Cost: Free to patients
Success rate: Oncology appeals have approximately 68% overturn rate

How to file: Contact Washington Office of Insurance Commissioner at 1-800-562-6900 or submit online at insurance.wa.gov

From our advocates: "We've seen Washington patients successfully overturn Keytruda denials by focusing on three key elements: complete biomarker documentation from CLIA labs, detailed prior treatment timelines with progression dates, and specific FDA indication citations. The state's external review process is particularly effective for oncology cases when clinical evidence is thorough."

Scripts & Templates

Patient Phone Script for Aetna

"Hello, I'm calling about a prior authorization denial for Keytruda (pembrolizumab) for my [cancer type]. My member ID is [ID number]. I'd like to request a peer-to-peer review with the medical director and understand my appeal options. Can you also confirm if this requires step therapy and what documentation you need?"

Clinic Staff Script for Peer-to-Peer

"I'm requesting a peer-to-peer review for [patient name, DOB] regarding the Keytruda denial. The patient has [cancer type] with PD-L1 CPS of [score] and has failed [prior treatments]. This is FDA-approved and NCCN-recommended for this indication. When can Dr. [name] speak with your medical director?"

Medical Necessity Appeal Template

"Patient [name] has metastatic [cancer type] (ICD-10: [code]) with documented progression on [prior therapy] as evidenced by [imaging date]. PD-L1 CPS testing via 22C3 IHC shows [score], meeting FDA criteria for pembrolizumab. NCCN guidelines recommend pembrolizumab as [line] therapy for this indication. Request approval for 200mg IV every 3 weeks per FDA labeling."

Costs & Financial Assistance

Keytruda Cost: Approximately $23,591 per 6-week dose (400mg)

Financial Assistance Options:

  • Merck Patient Assistance Program: Free drug for eligible uninsured patients
  • Keytruda Co-pay Program: $25/month for eligible commercially insured patients
  • CVS Health Foundation: Grants for cancer patients
  • Washington State Programs: Apple Health (Medicaid) for eligible residents

Contact: Call Merck at 1-855-257-3932 or visit keytruda.com/financial-support

When to Escalate to State Regulators

Contact the Washington Office of Insurance Commissioner if:

  • Aetna fails to respond within required timeframes
  • You believe the denial violates Washington insurance law
  • You need help navigating the appeals process

Contact Information:

  • Phone: 1-800-562-6900
  • Website: insurance.wa.gov
  • File complaint online or request external review assistance

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned to each payer's specific requirements, significantly improving approval rates for complex medications like Keytruda.

FAQ

How long does Aetna prior authorization take for Keytruda in Washington?
Standard reviews take 30-45 days. Expedited reviews (for urgent cases) are completed within 72 hours.

What if Keytruda is non-formulary on my Aetna plan?
Request a formulary exception by demonstrating medical necessity and that preferred alternatives are inappropriate or have failed.

Can I request an expedited appeal in Washington?
Yes, if your health could be seriously jeopardized by delays. Both Aetna internal appeals and Washington external reviews offer expedited timelines.

Does step therapy apply if I failed treatments in another state?
Yes, documented treatment failures from any location count toward step therapy requirements. Provide complete treatment records.

What biomarker testing does Aetna require for Keytruda?
PD-L1 CPS ≥1 (using 22C3 IHC assay), MSI-H/dMMR status, or TMB-H ≥10 mutations/megabase, depending on your cancer type and indication.

How much does external review cost in Washington?
External review through Washington's IRO process is completely free to patients.

What happens if the IRO overturns Aetna's denial?
The decision is binding on Aetna, and they must provide coverage for Keytruda as determined by the IRO.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and medical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For personalized help with complex appeals, consider consulting with specialists like those at Counterforce Health who focus on insurance authorization challenges.

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