By Counterforce Health Team in Opsumit (macitentan) —

How to Get Opsumit (Macitentan) Covered by Aetna CVS Health in Pennsylvania: 2025 Forms, Appeals & Contact Guide

Quick Answer: Opsumit (macitentan) requires prior authorization from Aetna CVS Health in Pennsylvania. Submit the 2024 PA form via fax (1-888-267-3277) or electronic portal with PAH diagnosis documentation, specialist consultation, and step therapy records. If denied, use Pennsylvania's new external review program—50% of appeals succeed. Start with your prescriber gathering clinical records today.

Table of Contents

Start Here: Verify Your Plan & Find Forms

Before starting your Opsumit (macitentan) prior authorization with Aetna CVS Health, confirm these essentials:

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all plans Aetna Precertification List
Formulary Status Specialty tier, non-preferred Member portal or formulary PDF
Step Therapy Usually required (try other PAH drugs first) Aetna PAH Policy
Prescriber Requirement PAH specialist (cardiologist/pulmonologist) PA form instructions
REMS Program Enrollment mandatory Opsumit REMS

First Step: Have your prescriber access the current Aetna CVS Health PA form for Opsumit at PrescriberPoint (verify with the source linked below).

Required Forms & Documentation

Core PA Requirements

Your prescriber must submit:

  1. Completed PA Form: Use the 2024 Aetna-specific Opsumit form
  2. Clinical Documentation:
    • PAH diagnosis with WHO Group 1 classification
    • Right heart catheterization results
    • Functional class assessment (NYHA/WHO)
    • Previous PAH medication trials and outcomes
    • Current symptoms and exercise capacity
  3. REMS Enrollment: Patient must be enrolled in the Opsumit REMS program before approval

Step Therapy Documentation

Aetna typically requires patients to try these first:

  • Phosphodiesterase-5 inhibitors (sildenafil, tadalafil)
  • Other endothelin receptor antagonists (ambrisentan, bosentan)
  • Document failures, intolerances, or contraindications
Clinician Corner: Your medical necessity letter should include: (1) specific PAH functional class with objective measures, (2) detailed previous therapy timeline with doses and durations, (3) clinical rationale citing FDA labeling or PAH guidelines, and (4) monitoring plan for hepatotoxicity and teratogenicity.

Submission Portals & Methods

Electronic Submission (Fastest)

  • Aetna Provider Portal: Available through Availity
  • CoverMyMeds: Electronic PA platform
  • Processing Time: Over 95% processed within 24 hours for complete submissions

Manual Submission

If electronic options aren't available, use the contact methods below.

Fax Numbers & Mailing Addresses

Specialty Drug Prior Authorization (Opsumit qualifies):

  • Fax: 1-888-267-3277
  • Phone: 1-800-294-5979 (Mon-Fri, 8 AM-6 PM CST)

Plan-Specific Contacts:

  • Commercial Plans: Use numbers above
  • Medicare Advantage: Fax 1-844-268-7263, Phone 1-866-503-0857
  • Aetna Better Health (Medicaid): Fax 1-877-363-8120

Mailing Address: Medical Exception to Pharmacy Prior Authorization Unit
1300 East Campbell Road
Richardson, TX 75081

Tip: Include a cover sheet with member ID, drug name, and "URGENT - PAH MEDICATION" for faster processing.

CVS Specialty Pharmacy Enrollment

Opsumit is dispensed through CVS Specialty Pharmacy for most Aetna members:

Transfer Process

  1. Contact CVS Specialty: 1-855-633-7673
  2. Required Information:
    • Approved PA confirmation
    • REMS enrollment verification
    • Shipping address and preferences
  3. Timeline: 3-5 business days after PA approval

What CVS Specialty Handles

  • REMS compliance monitoring
  • Pregnancy testing coordination (female patients)
  • Refill reminders and adherence support
  • Insurance coordination

Support Lines & Who to Call

For Patients:

  • Aetna Member Services: Number on your insurance card
  • CVS Specialty: 1-855-633-7673
  • Opsumit Patient Support: Available through manufacturer website

For Providers:

  • PA Status Check: 1-800-294-5979
  • Peer-to-Peer Review: Request through same number
  • Clinical Questions: Aetna medical directors available for consultation

Pennsylvania Appeals & External Review

If your Opsumit PA is denied, Pennsylvania offers robust appeal rights:

Internal Appeal (Required First Step)

  • Timeline: File within 180 days of denial
  • Decision Time: 30-45 days (72 hours for urgent)
  • Required: Medical records supporting necessity

Pennsylvania External Review (New 2024 Program)

After internal appeal denial, you can request independent review:

How to File:

Timeline: 4 months after final denial letter Success Rate: 50% of appeals overturned in 2024 Cost: Free to patients

From Our Advocates: "We've seen excellent results with Pennsylvania's external review program for specialty drugs. The key is submitting comprehensive clinical documentation that directly addresses why the standard step therapy drugs failed or were inappropriate. Include specific dates, doses, and documented side effects or lack of efficacy."

Common Denial Reasons & Solutions

Denial Reason How to Overturn
Step therapy not completed Document trials of required drugs with specific failures/intolerances
Not medically necessary Submit functional class assessment, exercise testing, hemodynamics
REMS not enrolled Complete enrollment before resubmission
Non-formulary status Request formulary exception with clinical justification
Prescriber not specialist Have cardiologist or pulmonologist submit/co-sign request

Cost Assistance Programs

Even with insurance approval, Opsumit can have high copays:

Manufacturer Support:

  • Janssen CarePath: Copay assistance and patient support programs
  • Eligibility: Commercial insurance patients (not government plans)

Foundation Assistance:

  • Patient Access Network Foundation: PAH-specific grants
  • HealthWell Foundation: Pulmonary hypertension fund

State Resources:

  • Pennsylvania PACE/PACENET: For seniors with prescription costs
  • Contact: 1-800-225-7223

FAQ

How long does Aetna CVS Health PA take in Pennsylvania? Over 95% of complete submissions are processed within 24 hours. Incomplete submissions may take 3-5 business days.

What if Opsumit is non-formulary on my plan? Request a formulary exception through the same PA process, emphasizing medical necessity and step therapy failures.

Can I request an expedited appeal if I'm already on Opsumit? Yes, if discontinuation poses serious health risks. Your doctor must certify the urgency.

Does step therapy apply if I failed other PAH drugs outside Pennsylvania? Yes, document all previous trials regardless of where they occurred. Out-of-state medical records are accepted.

What's the difference between internal and external appeals? Internal appeals are reviewed by Aetna; external appeals are reviewed by independent physicians through Pennsylvania's program.

How do I know if my appeal was successful? Aetna must notify you in writing within the decision timeline. Approved appeals result in immediate coverage.

About Counterforce Health: Counterforce Health specializes in turning insurance denials into successful appeals for patients, clinicians, and specialty pharmacies. Our platform analyzes denial letters and creates evidence-backed rebuttals that align with each payer's specific requirements, helping patients access critical medications like Opsumit more efficiently.

When navigating complex prior authorization requirements for specialty medications, having the right documentation and appeal strategy can make the difference between approval and denial. Counterforce Health helps streamline this process by identifying the specific evidence and clinical facts that payers expect to see in successful submissions.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances and plan terms. Always consult with your healthcare provider and insurance company for specific guidance. For additional help with insurance appeals in Pennsylvania, contact the Pennsylvania Insurance Department Consumer Services at 1-877-881-6388.

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