How to appeal an Aetna hiv prep & hiv treatment denial

The framework that applies to your appeal

Federal law gives you the right to a full and fair internal appeal, then an external review by an independent third party.

Aetna-specific note: Owned by CVS Health since 2018. CVS Caremark is the PBM. Aetna ASA administers self-funded ERISA plans. Meritain Health is Aetna's TPA brand.

What Aetna's policy requires for hiv prep & hiv treatment

Cited policy: Aetna Clinical Policy Bulletin (HIV/AIDS Treatment) + Aetna Clinical Policy Bulletin (PrEP)

Step therapy on TAF-based; site-of-care for LA injectables.

How Aetna denies hiv prep & hiv treatment — and how to counter it

Where Aetna pushes back: 1) Apretude 'non-formulary'; 2) Step therapy from TDF/FTC; 3) Site-of-care restrictions for LA.

Counter-arguments that hold up: HHS FAQ Part 47 requires coverage of AT LEAST ONE OPTION PER PrEP MODALITY including LA injectable. Document adherence challenges, stigma/privacy concerns, prior PrEP failure on oral, GI intolerance. HPTN 083 (cisgender MSM/TGW) and HPTN 084 (cisgender women) demonstrating superiority.

What Aetna typically denies for hiv prep & hiv treatment

Across Aetna's commercial and Medicare books, denials cluster around a small number of patterns. For hiv prep & hiv treatment, expect:

• UM-2575 medical necessity denials
• Prior auth absent
• Step therapy on specialty drugs
• Out-of-network ER reduction

Treatments most often denied in this category

These are the hiv prep & hiv treatment treatments most often flagged for prior auth, step therapy, or medical necessity review:

• Truvada PrEP (generic)
• Descovy PrEP
• Apretude LA PrEP
• Biktarvy
• Dovato
• Triumeq

How to submit the appeal to Aetna

1. Read the denial letter — note the exact denial reason code and the appeal deadline (180 days from the date on the letter).
2. Gather supporting documentation: physician letter of medical necessity, relevant clinical notes, peer-reviewed citations supporting the treatment for your indication, and the policy or coverage document Aetna cited in the denial.
3. File the appeal through Aetna's portal (members: https://www.aetna.com ; providers: https://www.aetnaprovider.com). Standard decision returns within 30 days; expedited urgent appeals return within 72 hours.
4. If denied again, request external review by an independent reviewer within 4 months of the final internal denial. In CT, the state insurance department coordinates external review for fully-insured plans; ERISA self-funded plans use a federal external review through DOL/EBSA.

Clinician or prior-auth team handling this on the practice side? See Aetna's prior-authorization criteria by drug: Aetna PA criteria on ApprovalHelp.