By Counterforce Health Team in Alecensa (alectinib) —

Do You Qualify for Alecensa (alectinib) Coverage by Aetna (CVS Health) in Georgia? Complete Decision Tree & Appeals Guide

Answer Box: Quick Eligibility Check

You likely qualify for Alecensa (alectinib) coverage by Aetna (CVS Health) if you have ALK-positive NSCLC (either metastatic/recurrent disease or adjuvant therapy after complete tumor resection with tumor ≥4cm or node-positive). First step today: Call the number on your Aetna insurance card to confirm Alecensa requires prior authorization through CVS Caremark, then gather your ALK test report and staging documentation. In Georgia, if denied, you have 60 days to file an external review through the Georgia Department of Insurance.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible": Document Checklist
  4. If "Possibly Eligible": Tests to Request
  5. If "Not Yet": Alternative Strategies
  6. If Denied: Georgia Appeals Path
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & Solutions
  9. FAQ: Georgia-Specific Questions

How to Use This Decision Tree

This guide helps patients and clinicians navigate Aetna (CVS Health) coverage for Alecensa (alectinib) in Georgia. Work through the eligibility questions below, then follow the appropriate pathway based on your results.

Before you start, verify your plan details by calling the member services number on your insurance card. Confirm that:

  • CVS Caremark manages your pharmacy benefit
  • Alecensa requires prior authorization
  • CVS Specialty is your designated specialty pharmacy

Eligibility Triage: Do You Qualify?

Step 1: Diagnosis Confirmation

Do you have ALK-positive non-small cell lung cancer (NSCLC)?

  • ✅ Yes, with FDA-approved ALK test → Continue to Step 2
  • ❓ ALK status unknown → See "Possibly Eligible" section
  • ❌ No ALK rearrangement → See "Not Yet" section

Step 2: Disease Stage and Treatment Intent

Which describes your situation?

Option A: Metastatic/Recurrent NSCLC

  • Advanced or metastatic ALK-positive NSCLC
  • May include brain metastases
  • Result: Likely eligible ✅

Option B: Adjuvant Therapy

  • Complete tumor resection completed
  • Tumor ≥4 cm OR node-positive disease
  • Result: Likely eligible ✅

Option C: Early-stage, small tumor

  • Tumor <4 cm and node-negative
  • Result: Not yet eligible ❌

Step 3: Prior Therapy (if applicable)

According to Aetna's 2024 policy, step therapy is not explicitly required for Alecensa in ALK-positive NSCLC, but documentation of treatment history strengthens medical necessity.

If "Likely Eligible": Document Checklist

Required Documentation

Gather these documents before your oncologist submits the prior authorization:

1. ALK Testing Results

  • Complete molecular pathology report
  • Must show ALK rearrangement via FDA-approved test
  • Include laboratory name and test method (FISH, IHC, or NGS)

2. Pathology and Staging

  • Original NSCLC pathology report
  • Current staging (TNM classification)
  • Imaging reports confirming metastatic sites (if applicable)

3. Treatment History

  • Complete list of prior systemic therapies
  • Dates, responses, and reasons for discontinuation
  • Documentation of any intolerances or contraindications

4. Clinical Documentation

  • Recent oncology visit notes
  • Performance status (ECOG 0-2 preferred)
  • Current symptoms and functional status

Submission Process

Electronic Prior Authorization (Fastest) Your oncologist should submit via CVS Caremark's electronic portal. This typically takes 5-7 business days for a decision.

Fax Submission If electronic submission isn't available, use the current Aetna Alecensa PA form and fax to 1-888-267-3277 (verify current number with your plan).

Expedited Review Request urgent processing if:

  • You have stage III or IV cancer
  • Delay could seriously jeopardize health
  • Standard review timeline would postpone critical treatment
Tip: Mark "URGENT CANCER TREATMENT" clearly on all forms and include a physician statement about clinical urgency.

If "Possibly Eligible": Tests to Request

Missing ALK Testing

If your ALK status is unknown:

  1. Request ALK testing from your oncologist
  2. FDA-approved tests include:
    • Vysis ALK Break Apart FISH Probe Kit
    • Ventana ALK (D5F3) CDx Assay
    • Comprehensive genomic profiling panels
  3. Timeline: Results typically available in 1-2 weeks
  4. Coverage: Most insurers cover ALK testing for advanced NSCLC

Insufficient Staging Information

If disease stage is unclear:

  • Request updated imaging (CT chest/abdomen/pelvis, brain MRI)
  • Obtain complete pathology review
  • Document tumor size and lymph node involvement for adjuvant cases

If "Not Yet": Alternative Strategies

Formulary Exception Request

If Alecensa is not on your plan's formulary:

  1. Your oncologist can request a formulary exception
  2. Provide evidence that formulary alternatives are inappropriate
  3. Include clinical rationale and guideline support

Step Therapy Override

If step therapy is required:

  1. Document contraindications to preferred agents
  2. Show evidence of prior treatment failures
  3. Cite NCCN guidelines supporting Alecensa as appropriate therapy

Off-Label Use Considerations

For non-standard indications, strengthen your case with:

  • Published clinical trial data
  • NCCN compendium listings
  • Peer-reviewed literature supporting use

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to identify specific requirements, then drafts point-by-point rebuttals using the right clinical evidence and payer-specific workflows.

If Denied: Georgia Appeals Path

Internal Appeal (First Step)

Timeline: 60 days from denial notice Process:

  1. Submit appeal via Aetna member portal or mail
  2. Include updated medical necessity letter addressing each denial reason
  3. Attach any missing documentation
  4. Request expedited review if medically urgent (72-hour decision)

Peer-to-Peer Review

When to request: For medical necessity denials Process:

  • Your oncologist calls Aetna's peer-to-peer line
  • Discusses case with Aetna medical director
  • Present clinical rationale and guideline support
  • Not a formal appeal level but may reverse decision

Georgia External Review

Timeline: 60 days from final internal denial Process:

  1. Submit application to Georgia Department of Insurance
  2. Call 1-800-656-2298 for assistance
  3. Independent physicians review your case
  4. Decision is binding on Aetna
  5. Free for consumers

Expedited External Review: Available for urgent cases (72-hour decision)

Note: Georgia's external review has strong consumer protections. The state requires insurers to accept the independent reviewer's decision and cover approved services.

Coverage Requirements at a Glance

Requirement Aetna (CVS Health) Criteria Documentation Needed
Prior Authorization Required for all plans Complete PA form
ALK Testing FDA-approved test required Molecular pathology report
Disease Stage Metastatic/recurrent OR adjuvant (≥4cm/node+) Staging reports
Specialty Pharmacy CVS Specialty typically required Coordinate with prescriber
Authorization Period 12 months initial approval Annual reauthorization
Age Restrictions Adult patients (≥18 years) Date of birth verification

Source: Aetna Specialty Pharmacy Clinical Policy Bulletin 2150-A

Common Denial Reasons & Solutions

Denial Reason How to Fix Required Documentation
Missing ALK test Submit molecular report FDA-approved ALK test results
Insufficient staging Provide complete workup Pathology + imaging reports
Medical necessity unclear Strengthen physician letter NCCN guidelines, clinical rationale
Non-formulary status Request exception Evidence alternatives inappropriate
Quantity limits exceeded Justify dosing FDA labeling, clinical notes

FAQ: Georgia-Specific Questions

How long does Aetna (CVS Health) prior authorization take in Georgia? Electronic submissions typically take 5-7 business days. Expedited reviews for urgent cancer cases are decided within 72 hours.

What if Alecensa is not on my formulary? Request a formulary exception through your oncologist. Include clinical evidence showing why formulary alternatives won't work for your specific situation.

Can I appeal directly to Georgia if Aetna denies my internal appeal? Yes. Georgia's external review process is available within 60 days of your final internal denial. Contact the Georgia Department of Insurance at 1-800-656-2298.

Does Georgia have special protections for cancer patients? Georgia allows expedited external review for urgent situations and requires insurers to accept binding decisions from independent reviewers.

What's the difference between a peer-to-peer review and an appeal? A peer-to-peer is an informal discussion between your oncologist and an Aetna medical director. An appeal is a formal review process with specific timelines and documentation requirements.

How much does external review cost in Georgia? External review through the Georgia Department of Insurance is free for consumers.

What if I miss the 60-day deadline for external review? Contact Georgia DOI immediately. In some cases, they may grant extensions, especially if you weren't properly notified of your rights.

Can I get financial help while waiting for approval? Yes. Genentech offers a co-pay program for eligible patients with commercial insurance, potentially reducing costs to $0 per month.

When insurance denials feel overwhelming, remember that Counterforce Health helps patients and clinicians navigate complex prior authorization requirements and appeal processes. Their evidence-based approach has helped many patients access critical cancer treatments by identifying specific payer requirements and crafting targeted responses.

Sources & Further Reading

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider regarding treatment decisions and insurance coverage questions. Coverage policies may change, and individual circumstances vary. Verify current requirements with your insurance plan and healthcare team.

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