By Counterforce Health Team in Turalio (pexidartinib) —

Do You Qualify for Turalio (Pexidartinib) Coverage by Aetna (CVS Health) in Illinois? Decision Tree & Next Steps

Quick Answer: Your Path to Turalio Approval

Yes, Aetna (CVS Health) covers Turalio (pexidartinib) in Illinois with prior authorization. You'll likely qualify if you have symptomatic TGCT not suitable for surgery, meet REMS program requirements, and provide complete documentation. First step today: Call CVS Specialty at 1-800-237-2767 to request the current PA form and verify your specific plan requirements. Most complete submissions are approved within 24-72 hours.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible": Your Document Checklist
  4. If "Possibly Eligible": Tests to Request
  5. If "Not Yet": Alternatives and Exceptions
  6. If Denied: Illinois Appeal Path
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & Solutions
  9. Illinois External Review Process
  10. FAQ

How to Use This Decision Tree

This guide walks you through Aetna's specific requirements for Turalio coverage in Illinois. Start with the eligibility questions below, then follow your path to the appropriate action steps. Each section includes the exact documents you'll need and where to submit them.

Important: Turalio requires enrollment in the FDA REMS program due to serious liver toxicity risks. Both you and your prescriber must complete this before any prescription can be filled.

Eligibility Triage: Do You Qualify?

Answer these questions to determine your likely approval path:

✅ Likely Eligible if ALL apply:

  • Confirmed TGCT diagnosis with imaging (MRI preferred)
  • Disease causes severe morbidity or functional limitations
  • Surgery is not feasible or would cause severe complications
  • You and your prescriber can enroll in REMS program
  • Baseline liver function tests are normal
  • No severe liver disease or contraindications

⚠️ Possibly Eligible if SOME apply:

  • TGCT diagnosis confirmed but surgical options unclear
  • Previous treatments tried but documentation incomplete
  • Mild liver function abnormalities
  • Insurance plan has step therapy requirements not yet met

❌ Not Yet Eligible if ANY apply:

  • No confirmed TGCT diagnosis
  • Surgery remains a viable first-line option
  • Active severe liver disease
  • Unable to comply with REMS monitoring requirements

If "Likely Eligible": Your Document Checklist

Submission Path: Fax complete packet to CVS Specialty at 1-855-633-7673 or call 1-800-237-2767.

Required Documents:

  • Completed PA form (request current version from CVS Specialty)
  • TGCT diagnosis confirmation:
    • Pathology report confirming tenosynovial giant cell tumor
    • MRI or CT imaging showing extent of disease
    • ICD-10 code (typically M12.2 series for TGCT)
  • Surgical ineligibility documentation:
    • Orthopedic/surgical consultation notes
    • Clear statement why surgery would cause severe morbidity or is not feasible
  • REMS program enrollment:
    • Prescriber REMS certification confirmation
    • Patient REMS enrollment form signed
    • Baseline liver function tests (ALT, AST, bilirubin, alkaline phosphatase)
  • Clinical notes documenting:
    • Symptom severity and functional limitations
    • Any prior treatments attempted
    • Treatment goals and expected outcomes

Timeline Expectations:

  • Complete submissions: 24-72 hours for approval
  • Missing documentation: 7-14 days with follow-up requests
  • Complex cases: Up to 30 days with possible peer-to-peer review

If "Possibly Eligible": Tests to Request

Additional Documentation Needed:

  1. Surgical consultation - Request referral to orthopedic surgeon specializing in soft tissue tumors for formal assessment of surgical options
  2. Complete imaging - Ensure MRI includes assessment of:
    • Joint involvement and capsule extension
    • Neurovascular structure proximity
    • Bone erosion or invasion
  3. Step therapy documentation - If your plan requires it, document trials of:
    • Imatinib (if attempted)
    • Other targeted therapies
    • Reasons for discontinuation or contraindication

Timeline to Re-apply:

  • Allow 2-4 weeks to gather additional documentation
  • Resubmit with all original materials plus new evidence
  • Consider requesting expedited review if symptoms are worsening

If "Not Yet": Alternatives and Exceptions

Immediate Options:

  1. Complete TGCT workup if diagnosis uncertain
  2. Surgical evaluation with soft tissue tumor specialist
  3. Formulary exception request for coverage while gathering documentation

Exception Request Process:

  • Call Aetna Precertification at 1-855-582-2025
  • Fax supporting documentation to 1-855-330-1716
  • Provide medical justification for why Turalio is medically necessary despite incomplete standard criteria

If Denied: Illinois Appeal Path

Illinois has strengthened patient appeal rights with automatic external review for medical necessity denials.

Level 1: Internal Appeal

  • Timeline: File within 180 days of denial
  • Decision: 15 business days (24 hours if expedited)
  • How to file: Call member services or submit written appeal

Level 2: Automatic External Review

New in 2025: Medical necessity denials are automatically forwarded for independent review unless you opt out.

  • Timeline: 4 months from final internal denial to request
  • Expedited: 72 hours if delay risks your health
  • Cost: Free to patients
  • Decision: Binding on Aetna

Illinois Resources:

  • Department of Insurance: 1-877-527-9431
  • Attorney General Health Care Helpline: 1-877-305-5145
  • External Review Forms: Illinois DOI website

Coverage Requirements at a Glance

Requirement Details Where to Find It
Prior Authorization Always required Aetna 2024 Precert List
Formulary Status Specialty tier, non-preferred Plan formulary document
REMS Program Mandatory enrollment Turalio REMS website
Step Therapy May require imatinib trial Plan-specific policy
Quantity Limit 28-day supply maximum CVS Specialty guidelines
Site of Care Specialty pharmacy only CVS Specialty network

Common Denial Reasons & Solutions

Denial Reason How to Overturn
"Not medically necessary" Submit surgical consultation confirming inoperability + functional assessment scores
"Experimental/investigational" Provide FDA approval letter + prescribing information showing approved indication
"Step therapy not met" Document imatinib trial/failure or contraindication with dates and clinical notes
"REMS not enrolled" Complete prescriber and patient REMS enrollment before resubmission
"Insufficient documentation" Ensure all items from checklist above are included with clear clinical rationale

Illinois External Review Process

Illinois's Health Carrier External Review Act provides strong patient protections:

Key Features:

  • Independent physician review by specialist in your condition
  • Randomized IRO assignment - Aetna cannot influence reviewer selection
  • Binding decisions with up to $50,000 penalties for non-compliance
  • No cost to patients - insurers pay all review fees

When to Use:

  • Medical necessity denials upheld on internal appeal
  • Coverage disputes involving FDA-approved treatments
  • Cases where clinical evidence supports coverage but insurer disagrees
From our advocates: We've seen Illinois patients successfully overturn TGCT treatment denials through external review when complete surgical consultation notes and functional assessments were provided. The key is demonstrating that surgery would cause "severe morbidity" - a specific term in Turalio's indication that resonates with independent reviewers.

FAQ

Q: How long does Aetna prior authorization take for Turalio in Illinois? A: Complete submissions typically receive approval within 24-72 hours. Incomplete documentation can extend the process to 14-30 days.

Q: What if Turalio isn't on my Aetna formulary? A: You can request a formulary exception with medical justification. Turalio is FDA-approved for TGCT, which strengthens exception requests.

Q: Can I get expedited approval if my condition is worsening? A: Yes. Request expedited review if delays would seriously jeopardize your health. Decisions must come within 24 hours for expedited requests.

Q: Do I need to try other medications first? A: This depends on your specific plan. Some require imatinib trials, while others may approve Turalio as first-line for inoperable TGCT.

Q: What if I can't afford the copay? A: Contact Daiichi Sankyo's patient assistance program through the Turalio website or ask about copay assistance cards.

Q: How do I find a TGCT specialist in Illinois? A: Ask for referrals to orthopedic oncologists or soft tissue tumor specialists at major medical centers like Northwestern, University of Chicago, or Rush University Medical Center.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by providing evidence-backed, payer-specific strategies. Our platform analyzes denial letters and creates targeted rebuttals aligned with each insurer's own policies, helping patients access the medications they need faster.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about treatment decisions and work with them to navigate insurance coverage requirements. Coverage policies may vary by specific plan and can change. Verify current requirements with your insurer and refer to your plan documents for definitive coverage information.

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