Aetna

Aetna, now part of CVS Health, is one of the largest commercial insurers in the U.S. Aetna uses clinical policy bulletins (CPBs) to determine coverage for specialty medications. Their prior authorization process is structured but can be navigated effectively with proper documentation.

Common Denial Patterns

• •Step therapy not completed — Aetna requires specific prior medication trials documented with dates and doses
• •Clinical policy bulletin criteria not met — each drug has a CPB with specific clinical requirements
• •Preferred biosimilar required before brand biologic
• •Quantity limits exceeded — Aetna enforces strict quantity limits on many specialty drugs
• •Non-formulary drug — requested medication not on Aetna's formulary for the specific plan

Step Therapy Approach

Aetna publishes detailed Clinical Policy Bulletins (CPBs) for each drug, specifying exact step therapy requirements. These are publicly available on Aetna's website. Step therapy typically requires 1–2 prior medication trials with documentation of failure, intolerance, or contraindication.

Appeal Process

Internal appeals must be filed within 180 days of denial. Aetna provides a standard appeal form and accepts appeals via mail, fax, or their provider portal. External review is available after internal appeal exhaustion. Peer-to-peer reviews can be requested and are often effective for specialty drug denials.

Tips for Appealing Aetna Denials

1. 1.Reference the specific Aetna CPB number for the drug in your appeal — this shows you've read their criteria
2. 2.Request a peer-to-peer with Aetna's medical director, especially for biologic and specialty drug denials
3. 3.Aetna's CPBs are publicly available — review them before submitting the initial PA to ensure all criteria are addressed
4. 4.For biosimilar step therapy exceptions, document treatment stability on current brand medication
5. 5.Use Aetna's provider portal for faster PA submission and status tracking