By Counterforce Health Team in Rapivab (peramivir) —

The Requirements Checklist to Get Rapivab (peramivir) Covered by Aetna (CVS Health) in Florida

Answer Box: Getting Rapivab (peramivir) Covered by Aetna (CVS Health) in Florida

Rapivab (peramivir) requires prior authorization from Aetna CVS Health as a specialty drug. To get approved: 1) Confirm influenza diagnosis within 48 hours of symptom onset with lab test, 2) Document contraindications to oral antivirals (oseltamivir/zanamivir), 3) Submit PA via Aetna provider portal with medical necessity letter. Standard decisions take 30-45 days; expedited reviews 72 hours. If denied, you have 180 days to appeal internally, then pursue Florida's external review through the Department of Financial Services.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding and Billing Requirements
  5. Documentation Packet
  6. Submission Process
  7. Specialty Pharmacy Routing
  8. After Submission: What to Expect
  9. Common Denial Reasons & How to Fix Them
  10. Appeals Process in Florida
  11. Printable Checklist
  12. FAQ

Who Should Use This Checklist

This checklist is designed for patients with Aetna (CVS Health) insurance in Florida who need Rapivab (peramivir) for laboratory-confirmed influenza, along with their healthcare providers and caregivers. You'll find this most helpful if:

  • Your doctor has prescribed Rapivab for acute, uncomplicated influenza
  • You need treatment within 48 hours of symptom onset
  • You cannot take oral antivirals like oseltamivir (Tamiflu) due to contraindications
  • You're facing a prior authorization requirement or denial

Expected outcome: Following this checklist significantly improves your chances of approval by ensuring all required documentation is complete and submitted correctly. Most well-documented requests that meet clinical criteria are approved, though initial denials are common when documentation is incomplete.

Member & Plan Basics

✓ Verify Active Coverage

  • Confirm your Aetna (CVS Health) plan is active and covers specialty medications
  • Check your member ID card and verify benefits via the Aetna member portal
  • Note your plan type (commercial, Medicare, Medicaid) as requirements may vary

✓ Understand Your Plan Structure

  • Formulary status: Rapivab typically requires prior authorization on most Aetna plans
  • Specialty tier: Usually covered under medical benefit for hospitalized patients; pharmacy benefit for outpatient use requires PA
  • Deductible: Verify if your deductible applies to specialty medications
  • Network requirements: Treatment must be at an in-network facility
Note: Aetna processes most specialty drug PAs through CVS Caremark. Verify your specific plan details as coverage can vary significantly between commercial, Medicare, and Medicaid products.

Clinical Criteria Requirements

✓ FDA-Approved Indication

  • Age requirement: Patient must be ≥6 months old
  • Diagnosis: Laboratory-confirmed influenza A or B
  • Timing: Treatment must begin within 48 hours of symptom onset
  • Severity: Indicated for acute, uncomplicated influenza

✓ Step Therapy Documentation

Most Aetna plans require documentation of why oral alternatives cannot be used:

Oral oseltamivir (Tamiflu) contraindications:

  • Severe nausea/vomiting preventing oral absorption
  • Known allergy or hypersensitivity
  • Prior intolerance or adverse reaction
  • Inability to swallow capsules

Inhaled zanamivir (Relenza) contraindications:

  • Asthma or COPD (risk of bronchospasm)
  • Respiratory compromise
  • Inability to use inhaler device

✓ Dosing Requirements

  • Adults/adolescents: 600 mg IV single dose over 15-30 minutes
  • Pediatrics (6 months-12 years): 12 mg/kg (maximum 600 mg) IV single dose
  • Renal adjustment: Dose reduction required if creatinine clearance <50 mL/min

Coding and Billing Requirements

✓ ICD-10 Diagnosis Codes

Use the most specific influenza code available:

  • J09.X: Influenza due to identified novel influenza A virus
  • J10.1: Influenza due to other identified influenza virus with other respiratory manifestations
  • J11.1: Influenza due to unidentified influenza virus with other respiratory manifestations

✓ HCPCS Coding

  • Primary code: J2547 (peramivir, 1 mg per unit)
  • Units to bill: 600 units for standard adult dose
  • Administration: Use appropriate infusion codes (96365 for initial IV infusion)

✓ Supporting Codes

  • Lab confirmation: 87804 (influenza A/B antigen detection) or 87637 (multiplex PCR)
  • Site of care: Ensure appropriate place of service code

Documentation Packet

✓ Provider Medical Necessity Letter

Your prescriber's letter must include:

Clinical presentation:

  • Exact date and time of symptom onset
  • Presenting symptoms and severity
  • Physical examination findings

Laboratory confirmation:

  • Type of test performed (rapid antigen, PCR, culture)
  • Results showing influenza A or B positive
  • Date test was performed

Contraindication justification:

  • Specific reasons why oral antivirals cannot be used
  • Prior treatment history and outcomes
  • Any allergies or intolerances documented

Treatment plan:

  • Proposed dose and administration schedule
  • Expected outcomes and monitoring plan
  • Clinical rationale for IV versus oral therapy

✓ Required Attachments

  • Complete medical records from the encounter
  • Laboratory test results
  • Prior treatment documentation (if applicable)
  • Allergy history or adverse reaction records
  • Hospital admission notes (if inpatient)
Tip: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and plan policies to create comprehensive rebuttals with the right clinical documentation.

Submission Process

✓ Choose Correct Submission Method

  • Primary: Aetna provider portal (fastest, provides confirmation)
  • Alternative: Fax to CVS Caremark specialty PA department
  • Verify current contact: Submission details can change; confirm via Aetna precertification page

✓ Complete PA Form Requirements

  • Use most current PA form version
  • Fill all required fields completely
  • Include prescriber NPI and DEA numbers
  • Verify patient demographics match insurance records exactly

✓ Request Expedited Review When Appropriate

For urgent cases within the 48-hour treatment window:

  • Clearly mark "EXPEDITED" or "URGENT" on submission
  • Include clinical justification for urgency
  • Provide direct prescriber contact for peer-to-peer review
  • Standard expedited timeline: 72 hours for decision

Specialty Pharmacy Routing

✓ CVS Specialty Pharmacy Requirements

  • Most Aetna plans route Rapivab through CVS Specialty
  • Verify network participation of your treatment facility
  • Confirm specialty pharmacy can deliver to your location in Florida

✓ Coordination Steps

  • Prescriber sends prescription to CVS Specialty after PA approval
  • Patient enrollment in specialty pharmacy program
  • Verification of insurance benefits and copay
  • Coordination with infusion center for administration
Note: CVS Specialty Pharmacy can be reached at 1-866-278-5108 for questions about drug availability and network participation.

After Submission: What to Expect

✓ Confirmation and Tracking

  • Immediate: Save confirmation number from portal submission
  • 24-48 hours: Verify receipt via member services if no confirmation received
  • Status checks: Monitor via provider portal or call member services

✓ Decision Timelines

  • Standard PA: 30-45 business days (varies by plan type)
  • Expedited PA: 72 hours maximum
  • Peer-to-peer: May be offered if initial review is unfavorable

✓ What to Record

  • Submission date and confirmation number
  • All correspondence dates and reference numbers
  • Names of representatives spoken with
  • Any additional information requested

Common Denial Reasons & How to Fix Them

Denial Reason How to Fix Documentation Needed
Symptom onset >48 hours Provide exact timeline documentation Time-stamped clinic notes, patient diary, emergency department records
No contraindication to oral therapy Strengthen medical necessity letter Detailed allergy history, prior adverse reactions, clinical assessment
Missing lab confirmation Submit positive influenza test Laboratory report showing influenza A or B positive
Incomplete clinical information Provide comprehensive medical records Full encounter notes, assessment, treatment plan
Non-formulary status Request formulary exception Comparative effectiveness data, clinical guidelines

✓ Strengthening Your Appeal

If initially denied, your appeal should address the specific denial reason and include:

  • Point-by-point response to denial rationale
  • Additional clinical evidence supporting medical necessity
  • Relevant FDA labeling and clinical guidelines
  • Prescriber attestation of clinical judgment

Appeals Process in Florida

✓ Internal Appeal (Level 1)

  • Deadline: 180 days from denial notice
  • Decision timeline: 30 days for standard, 72 hours for expedited
  • Submission: Via Aetna member portal or written request
  • Required: Copy of denial letter, additional clinical documentation

✓ External Review (Level 2)

Florida offers independent external review through the Department of Financial Services:

  • Eligibility: Must complete internal appeal first (with exceptions)
  • Deadline: 4 months after final internal denial
  • Process: Submit request via Florida DFS
  • Cost: No charge to consumer
  • Decision: Binding on the insurer if favorable

✓ Consumer Assistance

  • Florida Insurance Consumer Helpline: 1-877-693-5236
  • Online complaints: Available through Florida DFS website
  • Consumer advocates: Available to help navigate the process

When dealing with complex prior authorization requirements, platforms like Counterforce Health can help by ingesting denial letters and plan policies to create targeted appeals that align with each payer's specific requirements and deadlines.

Printable Checklist

Before Submission:

  • Active Aetna (CVS Health) coverage verified
  • Influenza diagnosis confirmed within 48 hours
  • Lab test positive for influenza A or B
  • Contraindications to oral antivirals documented
  • Medical necessity letter completed
  • All required attachments gathered
  • Correct ICD-10 and HCPCS codes identified

During Submission:

  • Current PA form used
  • All required fields completed
  • Expedited review requested if urgent
  • Confirmation number recorded
  • Submission method documented

After Submission:

  • Receipt confirmed within 48 hours
  • Status check schedule established
  • Decision timeline noted
  • Appeal strategy prepared if needed

FAQ

Q: How long does Aetna (CVS Health) prior authorization take in Florida? A: Standard PA decisions take 30-45 business days. Expedited reviews for urgent cases are completed within 72 hours. Timeline may vary by plan type.

Q: What if Rapivab is not on my formulary? A: You can request a formulary exception by demonstrating medical necessity and providing clinical justification for why covered alternatives are not appropriate.

Q: Can I get an expedited appeal if my PA is denied? A: Yes, if your condition is urgent and delaying treatment could seriously jeopardize your health. Clearly document the urgency in your appeal request.

Q: Does step therapy apply if I failed oral antivirals outside of Florida? A: Yes, prior treatment failures from any location should be documented and included in your PA request, along with medical records supporting the failure or intolerance.

Q: What happens if I miss the 48-hour treatment window during the PA process? A: Treatment effectiveness decreases after 48 hours. If urgent, request expedited review and consider peer-to-peer discussion with the medical director.

Q: Are there financial assistance programs for Rapivab? A: Contact BioCryst Pharmaceuticals, the manufacturer, for patient assistance program information. Some foundations also provide grants for antiviral medications.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions are made by your insurer based on your specific plan and clinical circumstances. Always consult with your healthcare provider and insurance company for guidance specific to your situation. Coverage policies and procedures may change; verify current requirements with official sources.

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