By Counterforce Health Team in Opdivo (nivolumab) —

How to Get Opdivo (Nivolumab) Covered by Aetna in Ohio: Forms, Appeals & Provider Contacts

Answer Box: Getting Opdivo (Nivolumab) Covered by Aetna in Ohio

Opdivo (nivolumab) requires prior authorization from Aetna in Ohio. Fastest path to approval: 1) Verify your specific Aetna plan covers Opdivo for your diagnosis, 2) Have your oncologist submit a prior authorization request with complete medical records and evidence of medical necessity, 3) If denied, file an internal appeal within 60 days (180 days for most Aetna plans). Ohio residents can request external review through the Ohio Department of Insurance within 180 days of final denial.

Table of Contents

  1. Start Here: Verify Your Plan Coverage
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Methods
  4. Specialty Pharmacy Setup
  5. Appeals Process for Ohio Residents
  6. Support Lines and Contacts
  7. Ohio Consumer Assistance Resources
  8. Common Denial Reasons and Solutions
  9. FAQ

Start Here: Verify Your Plan Coverage

Before requesting prior authorization, confirm that your specific Aetna plan covers Opdivo (nivolumab) for your diagnosis. Opdivo is covered by Aetna for multiple FDA-approved indications including melanoma, non-small cell lung cancer, head and neck cancer, urothelial carcinoma, esophageal cancer, and Hodgkin lymphoma.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required before dispensing Aetna PA requirements
Medical Necessity Must meet specific clinical criteria Aetna clinical policy
Formulary Status Covered for approved indications Aetna formulary
Dosing Requirements 240mg q2 weeks or 480mg q4 weeks FDA prescribing information
Note: Aetna considers Opdivo Qvantig (subcutaneous formulation) medically necessary only for members with contraindications to IV Opdivo, as there's insufficient evidence of superiority over the lower-cost IV alternative.

Prior Authorization Forms and Requirements

Required Documentation

Your oncologist must submit comprehensive documentation including:

  • Clinical information: Diagnosis with ICD-10 codes, staging, pathology reports
  • Treatment history: Prior therapies tried and failed, including dates and reasons for discontinuation
  • Medical necessity justification: Why Opdivo is appropriate for your specific case
  • Dosing plan: Proposed regimen (single agent or combination therapy)
  • Monitoring plan: How treatment response and side effects will be assessed

Medical Necessity Criteria

Aetna requires that Opdivo treatment meets specific criteria based on your cancer type. For example:

  • Melanoma: Adjuvant treatment after complete resection of stage III/IV disease, or treatment of unresectable/metastatic disease
  • NSCLC: First-line treatment in combination with ipilimumab and platinum-doublet chemotherapy (for tumors without EGFR/ALK mutations), or second-line treatment after progression
  • Head and neck cancer: Recurrent or metastatic squamous cell carcinoma

Submission Portals and Methods

For Healthcare Providers

Providers can submit prior authorization requests through multiple channels:

  • EviCore portal: Direct submission for prior authorizations
  • Phone: 1-888-622-7329 during business hours
  • Fax: Contact Aetna for current fax numbers (verify with source linked)

Required Provider Information

When submitting requests, providers need:

  • Aetna provider ID number
  • Patient's member ID and demographic information
  • Complete clinical documentation
  • Prescribing physician's NPI and DEA numbers

Specialty Pharmacy Setup

Most Opdivo prescriptions are filled through CVS Specialty Pharmacy, Aetna's preferred specialty pharmacy partner.

Enrollment Process

  1. Provider submission: Your oncologist submits the prescription and enrollment form to CVS Specialty
  2. Patient information required: Name, DOB, insurance cards (front and back), contact preferences
  3. Clinical details: Diagnosis codes, allergies, height/weight, site of care preference
  4. Fax completed forms to: 1-800-323-2445

Patient Portal Access

Once enrolled, you can create an online account to:

  • Refill prescriptions
  • Check order status
  • Message your CareTeam securely
  • Track shipments

Contact CVS Specialty CareTeam at 1-800-237-2767 for enrollment assistance.

Appeals Process for Ohio Residents

If your initial prior authorization is denied, you have specific rights under Ohio law.

Internal Appeals Timeline

  • Aetna Better Health of Ohio: 60 days from denial receipt
  • Other Aetna plans: 180 days from denial receipt
  • Expedited appeals: 36-72 hours for urgent situations

Filing Methods for Appeals

Phone: 1-833-711-0773 (TTY: 711), Monday-Friday 7am-8pm ET

Fax: 1-833-928-1259

Mail:

Aetna Better Health of Ohio
Grievance System Manager
PO Box 81040, 5801 Postal Road
Cleveland, OH 44181

External Review in Ohio

After exhausting internal appeals, Ohio residents can request external review through an Independent Review Organization (IRO).

  • Timeline: Must request within 180 days of final denial
  • Cost: Free to patients
  • Contact: Ohio Department of Insurance at 800-686-1526
  • Decision timeframe: 30 days for standard review, 72 hours for expedited

Support Lines and Contacts

For Patients

  • Aetna member services: Check your insurance card for plan-specific number
  • CVS Specialty: 1-800-237-2767
  • Ohio Department of Insurance: 800-686-1526

For Healthcare Providers

  • Medical/behavioral health: 1-888-632-3862 (TTY: 711)
  • Medicare Advantage: 1-800-624-0756 (TTY: 711)
  • Prior authorization: 1-888-622-7329

Ohio Consumer Assistance Resources

Ohio provides several resources to help residents navigate insurance appeals:

State Agencies

  • Ohio Department of Insurance: Oversees external review process and consumer complaints
  • UHCAN Ohio: Nonprofit advocacy providing consumer assistance
  • OSHIIP: Ohio Senior Health Insurance Information Program (for Medicare issues)

What to Ask When Calling

When contacting support lines, have ready:

  • Your member ID and group number
  • Denial letter or reference number
  • Prescribing physician's information
  • Specific questions about coverage criteria or appeal deadlines

Common Denial Reasons and Solutions

Denial Reason How to Address
"Not medically necessary" Submit peer-reviewed studies, clinical guidelines (NCCN, ASCO), and detailed physician letter
"Experimental/investigational" Provide FDA approval documentation and clinical policy citations
Missing biomarkers Submit pathology reports with PD-L1 expression or other relevant biomarkers
Wrong line of therapy Document prior treatment failures with dates and clinical notes
Insufficient staging Provide complete imaging reports and staging documentation
From our advocates: We've seen Ohio patients successfully overturn Opdivo denials by ensuring their oncologist includes specific failure documentation for prior therapies, including exact dates, dosing, and clinical reasons for discontinuation. This level of detail often makes the difference in approval decisions.

FAQ

Q: How long does Aetna prior authorization take in Ohio? A: Standard decisions typically take 30-45 days. Expedited reviews for urgent situations are completed within 36-72 hours.

Q: What if Opdivo is not on my formulary? A: You can request a formulary exception by demonstrating medical necessity and providing evidence that covered alternatives are inappropriate for your case.

Q: Can I get an expedited appeal if my cancer is progressing? A: Yes, if your treating physician certifies that delay could seriously jeopardize your health, you can request expedited review with decisions within 72 hours.

Q: What happens if external review denies my appeal? A: The IRO decision is binding on your insurer, but you retain the right to seek other remedies such as legal action or regulatory complaints.

Q: Does step therapy apply to Opdivo? A: Step therapy requirements vary by diagnosis and plan. Your oncologist can request an exception if you've already failed required prior therapies or if they're contraindicated.

Q: How much does Opdivo cost without insurance? A: List price is approximately $7,943 per 240mg vial. Bristol Myers Squibb offers patient assistance programs that may help reduce costs.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned to payer requirements, pulling appropriate clinical evidence and weaving it into appeals that meet procedural requirements while tracking deadlines.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances and plan specifics. Always consult your healthcare provider and insurance plan documents for personalized guidance. For official appeals assistance in Ohio, contact the Ohio Department of Insurance at 800-686-1526.

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