By Counterforce Health Team in Synagis (palivizumab) —

How to Get Synagis (Palivizumab) Covered by Aetna in Washington: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Synagis Approved by Aetna in Washington

Aetna requires prior authorization for Synagis (palivizumab) and prioritizes Beyfortus as first-line therapy. To get coverage in Washington: (1) Submit Aetna's Synagis precertification form with clinical documentation proving high-risk criteria, (2) demonstrate why Beyfortus is contraindicated or inappropriate, and (3) if denied, file an internal appeal within 180 days, then request external review through Washington's IRO process. Standard approval takes 30-45 days; expedited reviews complete within 72 hours for urgent cases.

Table of Contents

Understanding Aetna's Synagis Coverage Policy

Aetna significantly restricts Synagis coverage as of 2024, requiring patients to try Beyfortus (nirsevimab) first unless contraindicated. This step therapy approach reflects the insurer's preference for the newer, more cost-effective RSV prevention option.

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all plan types Aetna Precert List
Formulary Status Specialty tier with restrictions Aetna Policy
Step Therapy Beyfortus required first Aetna Guidelines
Quantity Limits Maximum 5 doses per RSV season Aetna Policy
Age Restrictions Varies by indication (typically <24 months) FDA Label

Prior Authorization Requirements

Aetna requires comprehensive documentation before approving Synagis. The process involves submitting their specific precertification form along with detailed clinical records.

Required Documentation

  • Aetna Synagis Precertification Request Form (download here)
  • Birth certificate with gestational age
  • NICU discharge summary
  • Current weight for dosing calculations
  • Cardiology or pulmonology consultation notes
  • Documentation of Beyfortus contraindication or failure

Submission Methods

  • Phone: (866) 752-7021
  • Fax: (888) 267-3277
  • CVS Caremark PA Fax: 1-855-296-0323 (for step therapy overrides)

Step-by-Step: Fastest Path to Approval

  1. Gather Clinical Records (Patient/Family)
    • Collect birth records, NICU notes, and specialist reports
    • Timeline: 1-2 days
  2. Complete Precertification Form (Prescriber)
    • Download and fill out Aetna's form
    • Include ICD-10 codes and dosing calculations
    • Timeline: Same day
  3. Document Step Therapy Exception (Prescriber)
    • Provide clinical justification for why Beyfortus cannot be used
    • Include allergy records or contraindication evidence
    • Timeline: 1 day
  4. Submit Complete Package (Clinic Staff)
    • Fax to (888) 267-3277 or call (866) 752-7021
    • Keep confirmation receipt
    • Timeline: Same day
  5. Follow Up on Review (Clinic Staff)
    • Standard review: 30-45 days
    • Expedited review: 72 hours (if urgent)
    • Timeline: Varies by urgency
  6. Prepare for Potential Denial (All Parties)
    • Gather additional evidence for appeal
    • Note appeal deadlines (180 days in Washington)
    • Timeline: Ongoing
  7. File Appeal if Denied (Patient/Prescriber)
    • Submit within 180 days to Aetna
    • Include new clinical evidence
    • Timeline: 30-45 days for decision

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
"Beyfortus not tried first" Submit allergy documentation or contraindication letter from specialist
"Not high-risk criteria" Provide cardiology/pulmonology consultation confirming high-risk status
"Exceeds quantity limits" Document medical necessity for additional doses with clinical justification
"Outside RSV season" Submit local virology data showing ongoing RSV activity
"Missing clinical documentation" Resubmit with complete NICU records and specialist notes

Appeals Process in Washington

Washington offers strong consumer protections for insurance denials, with multiple appeal levels and an independent external review process.

Internal Appeals with Aetna

First-Level Appeal:

  • Deadline: 180 days from denial
  • Timeline: 30 days for decision (45 days for complex cases)
  • Expedited Option: 72 hours for urgent medical situations
  • How to File: Submit written appeal through Aetna member portal or mail to address on denial letter

Required Elements:

  • Copy of original denial letter
  • Additional clinical documentation not previously submitted
  • Physician letter of medical necessity
  • Any new test results or specialist consultations

External Review in Washington

If Aetna upholds the denial, Washington residents can request an independent review through a certified Independent Review Organization (IRO).

External Review Process:

  • Eligibility: Must complete internal appeals first; service cost >$500
  • Deadline: 180 days from final internal denial
  • Timeline: 20-45 days for standard review, 72 hours for expedited
  • Cost: No charge to patient
  • How to File: Submit request to Aetna, who refers to IRO within 3 business days

Key Advantage: The IRO's decision is legally binding on Aetna and cannot be overturned by the insurer.

Medical Necessity Documentation

Counterforce Health helps patients and clinicians build stronger appeals by analyzing denial letters and crafting evidence-backed rebuttals. Their platform specializes in turning insurance denials into targeted appeals that address payer-specific criteria.

Clinician Corner: Medical Necessity Letter Checklist

Essential Elements:

  • Patient's specific high-risk diagnosis with ICD-10 codes
  • Gestational age and birth weight documentation
  • Current clinical status and ongoing medical needs
  • Contraindications to Beyfortus (if applicable)
  • Dosing rationale based on current weight
  • Treatment goals and expected outcomes

Supporting Evidence:

  • FDA labeling for approved indications
  • American Academy of Pediatrics guidelines (2014, reaffirmed 2019)
  • Clinical trial data showing 45% reduction in RSV hospitalizations
  • Specialist consultation notes from cardiology or pulmonology
Tip: Include specific language from Aetna's medical policy to demonstrate how your patient meets their criteria. Reference policy number 0318 in your appeal.

Templates and Scripts

Patient Phone Script for Aetna

"Hello, I'm calling about a prior authorization for my child's Synagis prescription. The denial letter references [denial code]. I'd like to understand the specific reason for denial and the appeals process. Can you also confirm the fastest way to submit additional clinical documentation?"

Clinic Staff Peer-to-Peer Request Script

"I'm requesting a peer-to-peer review for [patient name, DOB] regarding Synagis coverage. The patient has [specific high-risk condition] and cannot use Beyfortus due to [contraindication]. I have additional clinical documentation to discuss with the medical director."

Cost Savings Options

Even with insurance coverage, Synagis can be expensive. Several programs help reduce out-of-pocket costs:

  • Sobi Patient Assistance Program: Income-based assistance for eligible families
  • State Children's Health Insurance Program (CHIP): Additional coverage for qualifying families
  • Medicaid (Apple Health in Washington): Comprehensive coverage for eligible children
  • Hospital charity care programs: Financial assistance for treatment at qualifying facilities

Contact the manufacturer or your hospital's financial counselor to explore these options.

When to Escalate

If appeals through Aetna fail, Washington residents have additional options:

Washington State Insurance Commissioner

The Office of the Insurance Commissioner can help with insurance disputes and provides guidance on the external review process.

  • Consumer Advocacy Line: 1-800-562-6900
  • Online Complaint Form: Available at insurance.wa.gov
  • Services: Appeal guidance, complaint investigation, external review assistance

When to File a Complaint

Consider contacting the Insurance Commissioner if:

  • Aetna fails to respond within required timelines
  • The external review process is delayed or mishandled
  • You believe Aetna is inappropriately denying medically necessary care
  • Appeals are denied without adequate medical review

Frequently Asked Questions

How long does Aetna prior authorization take in Washington? Standard reviews take 30-45 business days. Expedited reviews for urgent cases are completed within 72 hours. You can request expedited review if delay could jeopardize your child's health.

What if Synagis is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and providing clinical documentation. The process is similar to prior authorization but may require additional justification.

Can I request an expedited appeal? Yes, if your child's health could be in serious jeopardy due to delay. Submit your expedited request in writing and clearly state the urgent medical circumstances.

Does step therapy apply if my child tried Beyfortus outside Washington? Previous Beyfortus use or contraindications from other states should be documented and submitted with your prior authorization request. Include all medical records from the previous treatment.

How many times can I appeal? Washington allows multiple levels of appeal: first-level internal appeal, second-level internal appeal (if available), and external review through an IRO. Each level has specific deadlines and requirements.

What happens if the external review upholds the denial? External review decisions are typically final and binding. However, you can still explore alternative options like manufacturer assistance programs or seek care through different providers or facilities.

Can I get Synagis at a specialty pharmacy? Yes, Aetna often requires specialty medications like Synagis to be filled through CVS Specialty Pharmacy. Your prescriber will need to coordinate with the specialty pharmacy for dispensing and administration.

Do I need a referral to see a pediatric cardiologist or pulmonologist? This depends on your specific Aetna plan. HMO plans typically require referrals, while PPO plans may allow direct access to specialists. Check your plan documents or call member services.

The appeals process can feel overwhelming, but Washington's strong consumer protections and external review system provide real opportunities to overturn inappropriate denials. Counterforce Health offers specialized support for families navigating complex insurance appeals, helping turn denials into approvals through targeted, evidence-based advocacy.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for specific coverage questions. Appeal rights and timelines may vary by plan type and state regulations.

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