By Counterforce Health Team in Opdivo (nivolumab) —

How to Get Opdivo (Nivolumab) Covered by Aetna (CVS Health) in Washington: Complete Prior Authorization Guide

Answer Box: Getting Opdivo Covered by Aetna (CVS Health) in Washington

Opdivo (nivolumab) requires prior authorization from Aetna (CVS Health) for all oncology indications in Washington. The fastest path to approval: 1) Verify if your plan uses medical or specialty pharmacy benefit, 2) Complete the Opdivo Injectable Medication Precertification Request form with complete clinical documentation, 3) Submit via Availity portal or fax. Standard decisions take 14-30 days; expedited (urgent) requests are processed within 72 hours. If denied, Washington residents can appeal internally within 180 days, then request external review through the Office of Insurance Commissioner.

Table of Contents

  1. Who This Guide Helps
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Timelines
  6. If You Need to Provide More Information
  7. If Your Request is Denied
  8. Appeals Process in Washington
  9. Renewal and Re-authorization
  10. Cost and Financial Assistance
  11. Quick Reference Checklist
  12. Frequently Asked Questions

Who This Guide Helps

This guide is designed for cancer patients and their healthcare teams seeking Opdivo (nivolumab) coverage through Aetna (CVS Health) plans in Washington state. Whether you're dealing with melanoma, lung cancer, kidney cancer, or other approved indications, we'll walk you through the exact forms, documentation, and appeal strategies that work.

Expected outcomes: With proper documentation, most Opdivo requests meeting FDA-approved or NCCN-guideline criteria are approved within 2-4 weeks. For denials, Washington's strong external review process has helped many patients overturn initial decisions.

Counterforce Health helps patients and clinicians navigate complex prior authorization processes by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and creates point-by-point rebuttals aligned to each plan's specific policies.

Before You Start: Verify Your Coverage

Step 1: Confirm Your Plan Type

Call the member services number on your Aetna ID card to verify:

  • Whether you have commercial, Medicare Advantage, or Medicaid managed care
  • If Opdivo is covered under medical benefit (buy-and-bill) or specialty pharmacy benefit
  • Your current deductible status and specialty drug copay/coinsurance

Step 2: Check Network Status

Confirm your oncologist and infusion center are in-network. For out-of-network providers, prior authorization may still be required, but coverage will be limited.

Step 3: Verify Formulary Status

Use the CVS Caremark formulary lookup tool or your member portal to check:

  • Opdivo's formulary tier (typically specialty Tier 4-5)
  • Prior authorization requirements
  • Any step therapy or quantity limit restrictions

Gather Required Documentation

Clinical Documentation Checklist

Essential Records:

  • Complete pathology report with diagnosis and histology
  • Current staging imaging (CT, PET, MRI within 3 months)
  • Recent clinic notes documenting ECOG performance status
  • Lab results (CBC, CMP, liver function, LDH)
  • Prior treatment history with dates, responses, and reasons for discontinuation

Biomarker Testing (when applicable):

  • PD-L1 expression (for NSCLC first-line combinations)
  • EGFR/ALK status (must be negative for certain NSCLC indications)
  • MSI-H/dMMR status (for specific tumor types)

Treatment Planning:

  • Proposed dosing schedule (e.g., 240 mg IV every 2 weeks)
  • Combination partners if applicable (ipilimumab, chemotherapy)
  • Site of care justification (office vs. hospital outpatient)
Tip: Aetna's medical policies require explicit documentation that the requested regimen aligns with FDA labeling or NCCN Category 1/2A recommendations. Include this language in your medical necessity letter.

Submit Your Prior Authorization Request

Choose the Correct Form

For Commercial Plans: Use the Opdivo Injectable Medication Precertification Request form

For Medicare Advantage: Use the Medicare Opdivo Precertification Request form

Submission Methods (in order of preference)

  1. Electronic Portal: Availity (fastest processing)
  2. Fax: Use the number provided on the specific form
  3. Mail: Address listed on the form (slowest option)

Key Form Sections to Complete Carefully

  • Disease-specific checkboxes: Match exactly to your indication (e.g., "unresectable or metastatic melanoma")
  • Line of therapy: Clearly indicate first-line, subsequent, adjuvant, or maintenance
  • Combination regimen details: Specify all drugs, doses, and schedules
  • Clinical rationale: Reference specific NCCN categories or FDA labeling

Follow-Up and Timelines

Standard Processing Times

Request Type Timeline Notes
Standard PA 14-30 days Commercial and Medicare
Expedited/Urgent 72 hours When delay would jeopardize health
Incomplete submissions Additional 14 days After missing info provided

Follow-Up Schedule

Week 1: Confirm receipt via portal or phone Week 2: Check status if no response Week 3: Call member services if approaching deadline Week 4: Consider expedited review request if urgent

Sample Status Check Script

"Hello, I'm calling to check the status of a prior authorization request for Opdivo for patient [Name], member ID [Number]. The request was submitted on [Date]. Can you provide the current status and expected decision date?"

If You Need to Provide More Information

Aetna may request additional documentation through a "more information needed" letter. Common requests include:

Medical Necessity Questions:

  • More detailed treatment history
  • Updated imaging showing disease progression
  • Performance status documentation
  • Contraindications to alternative therapies

Documentation Fixes:

  • Complete biomarker results
  • Staging clarification
  • Prior therapy failure documentation
Note: Respond within the specified timeframe (typically 14 days) to avoid automatic denial. Submit via the same method as your original request.

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason How to Address
"Not medically necessary" Provide NCCN guideline citations and peer-reviewed evidence
"Insufficient clinical information" Submit complete treatment history and biomarker results
"Step therapy not met" Document prior therapy failures or contraindications
"Off-label use" Request medical exception with supporting literature

Peer-to-Peer Review Request

Before formal appeals, request a peer-to-peer discussion with Aetna's medical director:

  • Call within 48 hours of denial notice
  • Prepare clinical summary and guideline references
  • Document reviewer name, date, and discussion points

Appeals Process in Washington

Washington state provides robust appeal rights for Aetna members through multiple levels:

Internal Appeals (Levels 1-2)

First-Level Appeal:

  • Deadline: 180 days from denial notice
  • Timeline: 30-45 business days (72 hours if expedited)
  • Submission: Aetna Appeals Resolution Team, PO Box 14462, Lexington, KY 40512

Required Documentation:

  • Original denial letter
  • Medical necessity letter addressing specific denial reasons
  • Updated clinical notes and imaging
  • Peer-reviewed literature supporting your indication
  • NCCN or other guideline citations

Second-Level Appeal:

  • File within 60 days of first-level denial
  • Use same submission methods
  • Include first-level denial letter

External Review (Independent Review Organization)

If internal appeals fail, Washington residents can request external review through the Office of Insurance Commissioner (OIC):

  • Deadline: 180 days from final internal denial
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Process: Submit request to OIC, which assigns a certified IRO
  • Decision: Binding on Aetna if overturned
Washington Advantage: The state's external review process has independent medical specialists who can override insurer medical necessity definitions when they're found unreasonable or inconsistent with standard practice.

When to Contact Washington OIC

Call the Consumer Advocacy line at 1-800-562-6900 if:

  • You're unsure about appeal deadlines
  • Aetna fails to respond within required timeframes
  • You need help navigating the external review process
  • You believe your denial was inappropriate

Renewal and Re-authorization

Opdivo typically requires re-authorization every 6-12 months. Plan ahead by:

30 Days Before Current Auth Expires:

  • Schedule updated imaging
  • Obtain recent clinic notes documenting continued benefit
  • Confirm no disease progression or unacceptable toxicity

Renewal Documentation:

  • Treatment response assessment
  • Toxicity evaluation and management
  • Continued medical necessity justification
  • Updated performance status

Counterforce Health's platform can help track renewal deadlines and prepare documentation packages that address common re-authorization requirements.

Cost and Financial Assistance

Manufacturer Support Programs

Bristol Myers Squibb Access Support:

  • Commercial copay assistance (may reduce costs to $25-50 per infusion)
  • Patient assistance program for uninsured/underinsured
  • Benefits investigation and prior authorization support

Enrollment: Contact BMS Access Support or ask your oncology team's financial counselor for assistance.

Additional Resources

  • Washington state assistance: Check if you qualify for Apple Health (Medicaid) expansion
  • Foundation grants: Organizations like CancerCare and Patient Advocate Foundation offer emergency assistance
  • Hospital charity care: Many Washington hospitals have financial assistance programs
Important: Manufacturer copay cards cannot be used with Medicare, Medicaid, or other government insurance due to federal anti-kickback laws.

Quick Reference Checklist

Before Submitting PA:

  • Verify plan type and benefit channel (medical vs. pharmacy)
  • Confirm network status of providers
  • Gather complete clinical documentation
  • Check biomarker requirements for your indication
  • Obtain correct Aetna form (commercial vs. Medicare)

At Submission:

  • Complete all form sections accurately
  • Include medical necessity letter with guideline citations
  • Submit via preferred electronic method
  • Retain confirmation of submission
  • Calendar follow-up dates

If Denied:

  • Read denial letter carefully for specific reasons
  • Request peer-to-peer review within 48 hours
  • Prepare appeal documentation addressing each denial point
  • Consider expedited appeal if treatment is urgent
  • Know your external review rights in Washington

Frequently Asked Questions

Q: How long does Aetna prior authorization take for Opdivo in Washington? A: Standard requests take 14-30 days. Expedited (urgent) requests must be processed within 72 hours when delay would seriously jeopardize health.

Q: What if Opdivo is not on my Aetna formulary? A: Request a medical exception using the Prescription Drug Medical Exception form with supporting clinical literature.

Q: Can I appeal an Aetna denial if I live in Washington? A: Yes. Washington provides strong appeal rights including internal appeals (180-day deadline) and external review through independent organizations.

Q: Does step therapy apply to Opdivo for all indications? A: Step therapy requirements vary by indication. For example, first-line NSCLC combinations may not require prior therapy, while subsequent therapy typically requires documented progression on standard treatments.

Q: What biomarker testing is required for Opdivo approval? A: Requirements depend on indication. NSCLC first-line combinations require EGFR/ALK-negative status and may require PD-L1 testing. Melanoma and RCC typically don't require specific biomarkers.

Q: Can my oncologist request an expedited review? A: Yes, when delay would seriously jeopardize your health. Expedited reviews must be completed within 72 hours for commercial plans.

Q: What happens if Aetna misses their decision deadline? A: Under federal law, if Aetna fails to make a decision within required timeframes, your request may be deemed approved.

Q: Are there alternatives if Opdivo is denied? A: Alternatives depend on your cancer type and may include other PD-1/PD-L1 inhibitors (Keytruda, Libtayo), targeted therapies, or chemotherapy. Your oncologist can help determine appropriate alternatives.

Sources & Further Reading

Disclaimer: This guide provides educational information about insurance coverage and appeal processes. It is not medical advice. Always consult with your healthcare team about treatment decisions and work with your insurance company for the most current coverage information. For assistance with complex appeals, consider consulting with patient advocacy organizations or Counterforce Health, which specializes in turning insurance denials into successful appeals.

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