By Counterforce Health Team in Opdivo (nivolumab) —

How to Get Opdivo (Nivolumab) Covered by Aetna CVS Health in Pennsylvania: Complete Guide with Forms, Appeal Scripts, and Success Strategies

Answer Box: Getting Opdivo Covered by Aetna CVS Health in Pennsylvania

Aetna requires prior authorization for Opdivo (nivolumab) in Pennsylvania. Your fastest path: Have your oncologist submit a complete prior authorization request with detailed medical necessity documentation, prior therapy failure records, and FDA-indicated diagnosis codes. If denied, request a peer-to-peer review within 14 days, then file an internal appeal within 180 days. Pennsylvania's new external review program overturns 53% of denials. First step today: Contact your oncologist to gather treatment history and request they initiate the prior authorization process at least 2 weeks before your planned treatment start date.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Common Denial Reasons & How to Fix Them
  4. Clinician Corner: Medical Necessity Documentation
  5. Appeals Playbook for Pennsylvania
  6. Phone Scripts & Templates
  7. Cost Savings and Patient Support
  8. When to Escalate to State Regulators
  9. Frequently Asked Questions

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required Yes, for all oncology indications Aetna provider portal or member ID card Aetna 2025 Precertification List
Formulary Status Varies by plan; may require exception Member formulary or Aetna website CVS Caremark Formulary
Step Therapy May apply; prior therapy documentation required Aetna medical policy Aetna PD-1/PD-L1 Policy
Site of Care Restrictions May require specific infusion centers Prior auth determination Aetna Specialty Pharmacy
Appeals Deadline 180 days from denial Member handbook Aetna External Review

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient & Oncologist)

Who: Patient and clinical team
Timeline: 1-2 weeks before treatment
Documents needed:

  • Complete pathology/biopsy reports confirming diagnosis
  • Detailed treatment history with dates and outcomes
  • Current staging and lab results
  • Insurance card and member ID

2. Complete Prior Authorization Request (Oncologist)

Who: Prescribing oncologist or authorized staff
How to submit: Aetna provider portal or fax
Timeline: Allow 30-45 days for standard review
Key forms: Opdivo Prior Authorization Form

3. Submit Complete Medical Necessity Package

Must include:

  • FDA-indicated diagnosis with ICD-10 codes
  • Prior therapy failures or contraindications
  • Clinical notes supporting guideline-based use (NCCN)
  • Relevant biomarkers (PD-L1, BRAF if applicable)

4. Track Authorization Status

How: Aetna provider portal or call 1-866-638-1232
Timeline: Check status after 7-10 business days
Next steps: If approved, coordinate with CVS Specialty for fulfillment

5. If Denied: Request Peer-to-Peer Review

Timeline: Within 14 days of denial
Who initiates: Prescribing physician
Purpose: Direct discussion with Aetna medical director

6. File Internal Appeal (If P2P Unsuccessful)

Timeline: Within 180 days of denial
Required: Written appeal with additional documentation
Expected response: 30-45 days (expedited available for urgent cases)

7. External Review Through Pennsylvania (Final Option)

Timeline: Within 4 months of final internal denial
Success rate: 53% overturn rate in Pennsylvania
How to file: Pennsylvania Insurance Department or call (877) 881-6388

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Insufficient medical necessity" Submit detailed clinical rationale with NCCN guidelines Treatment history, staging reports, guideline citations
"Missing prior therapy documentation" Provide complete treatment timeline with failure rationale Medical records showing inadequate response or intolerance
"Incorrect diagnosis codes" Verify and resubmit with precise ICD-10 codes Updated pathology reports, physician attestation
"Incomplete forms" Review and resubmit all required sections Complete Opdivo PA form
"Non-formulary drug" Request formulary exception Medical necessity letter explaining why alternatives aren't suitable
From Our Advocates: In our experience helping patients navigate Opdivo approvals, the most successful appeals include a clear timeline showing why standard treatments failed or weren't appropriate, combined with specific citations from NCCN guidelines. One common mistake we see is submitting generic medical necessity letters—Aetna responds much better to case-specific documentation that directly addresses their published criteria.

Clinician Corner: Medical Necessity Documentation

Essential Elements for Your Medical Necessity Letter

Patient Background:

  • Specific cancer diagnosis with stage and histology
  • Performance status and relevant comorbidities
  • Treatment goals (curative vs. palliative intent)

Prior Treatment Documentation:

  • Complete chronological treatment history
  • Specific reasons for treatment failures or discontinuation
  • Contraindications to standard alternatives
  • Response assessment with objective measures

Clinical Rationale for Opdivo:

  • FDA-approved indication alignment
  • NCCN guideline support with specific recommendation level
  • Biomarker status supporting use (if applicable)
  • Expected clinical benefit based on trial data

Key Guideline References:

Appeals Playbook for Pennsylvania

Internal Appeal Process

Level 1: Standard Internal Appeal

  • Deadline: 180 days from denial
  • How to file: Written request via Aetna member portal or mail
  • Timeline: 30 days for decision (45 days for complex cases)
  • Required: Denial letter, additional medical records, physician statement

Expedited Internal Appeal

  • When to use: Urgent medical situations
  • Timeline: 72 hours for decision
  • Required: Physician certification of urgency

Pennsylvania External Review

Eligibility: After exhausting internal appeals, cost >$500

  • Success rate: 53% overturn rate in 2024
  • Timeline: 45 days for standard review, 72 hours for expedited
  • How to file: Online portal or call (877) 881-6388
  • Required documents: Final denial letter, medical records, physician statement
  • Binding: Yes, Aetna must comply with favorable decisions

Phone Scripts & Templates

Patient Script for Calling Aetna

"Hi, I'm calling about a prior authorization request for Opdivo. My member ID is [number]. Can you please tell me the status of my request submitted on [date]? If it's been denied, I'd like to understand the specific reasons and request information about the appeals process."

Clinic Staff Script for Peer-to-Peer Request

"I'm calling to request a peer-to-peer review for [patient name], member ID [number]. The prior authorization for Opdivo was denied on [date]. Dr. [name] would like to discuss the medical necessity with your reviewing physician. When can we schedule this call?"

Email Template for Medical Records Request

Subject: Urgent: Medical Records Needed for Insurance Appeal - [Patient Name]

"We need complete treatment records for [patient] to support an insurance appeal for Opdivo coverage. Please provide:

  • All oncology visit notes from [date range]
  • Pathology reports
  • Imaging studies with radiologist interpretations
  • Laboratory results
  • Documentation of prior treatment responses

Timeline is urgent due to appeal deadlines. Please send within 48 hours if possible."

Cost Savings and Patient Support

Bristol Myers Squibb Patient Support

  • Bristol Myers Squibb Access Support: Patient assistance programs and copay support
  • Eligibility: Varies by insurance type and income
  • Contact: Check manufacturer website for current programs

CVS Specialty Pharmacy Services

CVS Specialty, which distributes Opdivo in Pennsylvania, offers comprehensive support including:

  • 24/7 clinical support team
  • Home delivery or retail pickup options
  • Prior authorization assistance through Specialty Expedite program
  • Contact: 1-888-493-5386

Pennsylvania-Specific Resources

  • Pennsylvania Insurance Department Consumer Services: (877) 881-6388
  • Pennsylvania Health Law Project: Free legal assistance for complex appeals
  • Pennie Customer Service: For marketplace plan issues

When to Escalate to State Regulators

Contact the Pennsylvania Insurance Department if:

  • Aetna fails to respond within required timeframes
  • You believe the denial violates state or federal law
  • The insurer isn't following their own policies
  • You need help understanding your appeal rights

Contact Information:

For complex cases involving multiple denials or systemic issues, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned to the plan's own rules.

Frequently Asked Questions

How long does Aetna prior authorization take for Opdivo in Pennsylvania? Standard decisions take 30-45 days, though Aetna claims 95% of complete requests are approved within 24 hours. Expedited reviews for urgent cases are completed within 72 hours.

What if Opdivo is not on my Aetna formulary? You can request a formulary exception by providing medical necessity documentation. Your oncologist must demonstrate why formulary alternatives aren't appropriate for your specific case.

Can I get an expedited appeal if my cancer is progressing? Yes, if your physician certifies that delays could seriously jeopardize your health. Expedited internal appeals are decided within 72 hours, and Pennsylvania's external review offers 72-hour decisions for urgent cases.

Does step therapy apply to Opdivo for advanced cancer? Step therapy requirements vary by indication and plan. For FDA-approved uses, Aetna typically requires documentation of appropriate prior therapies rather than forcing additional treatment trials.

What happens if Pennsylvania's external review overturns my denial? The decision is binding on Aetna. They must provide coverage immediately and may need to reimburse you for any out-of-pocket costs incurred during the appeal process.

How much does Opdivo cost without insurance in Pennsylvania? List price is approximately $7,943 per 240mg vial, with total regimen costs varying by weight and treatment duration. Patient assistance programs may be available for eligible patients.

Can Counterforce Health help with my Opdivo appeal? Yes, Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by analyzing denial letters and crafting targeted appeals with evidence-backed rebuttals aligned to each plan's specific requirements.

What if I have both Medicare and Aetna coverage? Coordination of benefits can be complex. Contact both insurers to understand which is primary for your Opdivo coverage, and ensure prior authorization is obtained from the correct payer.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies and procedures can change. Always verify current requirements with Aetna and consult with your healthcare team for medical decisions. For personalized assistance with complex appeals, consider consulting with organizations like Counterforce Health that specialize in insurance authorization processes.

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