By Counterforce Health Team in Emflaza (deflazacort) —

Get Emflaza (Deflazacort) Covered by Aetna in Georgia: Complete Prior Authorization Guide

Quick Answer: Emflaza Coverage by Aetna in Georgia

Yes, Aetna covers Emflaza (deflazacort) for Duchenne muscular dystrophy patients 2+ years old, but requires prior authorization and step therapy. Your fastest path to approval: 1) Have your neurologist document failed trials of prednisone/prednisolone due to weight gain or behavioral issues, 2) Submit the prior authorization through Aetna's provider portal with genetic testing confirming DMD, and 3) Enroll with CVS Specialty pharmacy. Start today by calling your specialist to gather documentation of previous steroid trials and side effects.

Georgia residents have 180 days to appeal denials internally, then 60 days for external review through the Georgia Department of Insurance.

Table of Contents

  1. Coverage Basics: Is Emflaza Covered?
  2. Prior Authorization Process
  3. Timeline and Urgency
  4. Step Therapy Criteria
  5. Costs and Financial Assistance
  6. Denials and Appeals in Georgia
  7. CVS Specialty Pharmacy Enrollment
  8. Common Problems and Solutions
  9. FAQ: Most Asked Questions
  10. Sources and Further Reading

Coverage Basics: Is Emflaza Covered?

Emflaza (deflazacort) is covered by most Aetna plans in Georgia, but it's classified as a specialty medication requiring prior authorization. The drug is typically placed on a high formulary tier (Tier 4 or 5) with coinsurance ranging from 20-33% rather than a flat copay.

Coverage at a Glance

Requirement Details Where to Verify
Prior Authorization Yes, required for all plans Aetna 2025 Precertification List
Formulary Tier Specialty (Tier 4-5) Your plan's formulary document
Step Therapy Must try prednisone/prednisolone first Aetna Emflaza Policy
Age Requirement 2+ years old FDA labeling requirement
Specialty Pharmacy CVS Specialty required Aetna specialty drug policy
Prescriber Neurologist or DMD specialist Prior authorization criteria

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Confirm DMD Diagnosis (Patient/Family)
    • Gather genetic testing results showing DMD gene mutation
    • Or obtain muscle biopsy showing absent dystrophin
    • Timeline: Can be done immediately if tests already completed
  2. Document Steroid Trial Failures (Prescriber)
    • Chart notes showing prednisone/prednisolone caused unmanageable weight gain (BMI in overweight/obese category)
    • Or psychiatric/behavioral issues lasting 6+ weeks (aggression, irritability, abnormal behavior)
    • Timeline: Review existing records or schedule follow-up if needed
  3. Submit Prior Authorization (Prescriber's Office)
    • Use Aetna provider portal (Availity) or fax submission
    • Include all required documentation listed above
    • Timeline: Submit at least 2 weeks before planned start date
  4. Enroll with CVS Specialty (Patient/Prescriber)
  5. Follow Up on Authorization (Patient/Prescriber)
    • Check status through Aetna provider portal
    • Call Aetna Pharmacy Precertification if needed
    • Timeline: Decisions typically within 30-45 days
Clinician Corner: Your medical necessity letter should emphasize that deflazacort has a more favorable side effect profile than prednisone/prednisolone for long-term use in DMD patients, citing the documented weight gain or behavioral issues experienced during previous steroid trials. Include specific BMI measurements or behavioral assessment scores when available.

Timeline and Urgency

Standard Prior Authorization Timeline

  • Aetna review period: 30 days for pre-service requests
  • Recommended submission: At least 2 weeks before needed start date
  • CVS Specialty enrollment: 3-5 business days after forms received

Expedited/Urgent Requests

If your patient's condition is deteriorating rapidly:

  • Request expedited review through Aetna (typically 72 hours)
  • Note medical urgency in PA submission
  • Have prescriber available for peer-to-peer review if requested

Important: In Georgia, you can request external review concurrent with an expedited internal appeal if delay poses serious risk to the patient's health.

Step Therapy Criteria

Aetna requires documented trial and failure of prednisone or prednisolone before approving Emflaza. The failure must be due to:

Acceptable Reasons for Step Therapy Override

Reason Documentation Required Notes
Unmanageable weight gain BMI charts showing overweight/obese category during steroid treatment Most common approval reason
Persistent psychiatric issues Chart notes of behavioral problems lasting 6+ weeks of treatment Include aggression, irritability, mood changes
Other significant side effects Detailed documentation of adverse effects Case-by-case review

What Doesn't Qualify

  • General concern about potential side effects (must have actual documented experience)
  • Patient/family preference without medical justification
  • Cost considerations alone

Costs and Financial Assistance

Typical Out-of-Pocket Costs

  • Coinsurance: 20-33% of drug cost (varies by plan)
  • Monthly cost estimate: Can range from hundreds to over $1,000 depending on your specific Aetna plan
  • Deductible: May apply before coinsurance kicks in

Financial Assistance Options

PTC Cares™ Patient Support Program

CVS Specialty Financial Support

  • Reviews available assistance programs during enrollment
  • Helps coordinate manufacturer programs
  • Call 1-888-280-1190 for details
Note: Manufacturer copay cards typically cannot be used with Medicare or Medicaid plans, but may be available for commercial Aetna plans.

Denials and Appeals in Georgia

Common Denial Reasons and Solutions

Denial Reason How to Fix Required Documentation
Insufficient DMD documentation Submit genetic testing or muscle biopsy results Lab reports confirming DMD gene mutation
No documented steroid trial Provide chart notes of prednisone/prednisolone experience Weight charts, behavioral assessments
Non-specialist prescriber Have neurologist co-sign or transfer prescription Specialist consultation notes
Missing prior authorization Resubmit complete PA request All required forms and documentation

Georgia Appeals Process

Internal Appeal with Aetna

  • Deadline: 180 days from denial date
  • Timeline: 30 days for pre-service, 60 days for post-service appeals
  • How to file: Call 1-888-632-3862 or submit through member portal

External Review (Georgia Department of Insurance)

  • Deadline: 60 days after final internal denial
  • Timeline: 30 business days (standard) or 72 hours (expedited)
  • Cost: Free to consumers
  • Contact: Georgia DOI Consumer Services at 1-800-656-2298
  • Decision: Binding on Aetna by Georgia law

When navigating insurance denials for specialty medications like Emflaza, having the right documentation and appeal strategy is crucial. Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to create point-by-point rebuttals aligned with payer requirements.

Appeal Script for Patients

"I'm calling to appeal the denial of Emflaza for my [child/family member] with Duchenne muscular dystrophy. We have genetic testing confirming the DMD diagnosis and documented side effects from prednisone including [specific issues like weight gain/behavioral problems]. I'd like to start an internal appeal and get the required forms."

CVS Specialty Pharmacy Enrollment

All Emflaza prescriptions through Aetna must be filled at CVS Specialty. Here's how to enroll:

Enrollment Process

  1. Provider completes CVS Specialty Deflazacort Enrollment Form
  2. Submit via:
    • Fax: 1-855-297-1270
    • Phone: 1-888-280-1190
    • E-prescribe through EMR system
  3. CVS Specialty contacts patient within 1-2 business days to:
    • Verify information and insurance
    • Discuss delivery options (home, office, local CVS)
    • Review financial assistance programs
    • Coordinate prior authorization if needed

Required Information

  • Patient demographics and insurance details
  • Prescriber NPI and DEA numbers
  • DMD diagnosis documentation
  • Previous steroid trial information

Common Problems and Solutions

Solution: This is standard for Aetna specialty drugs. CVS Specialty will contact you to coordinate delivery and services. Call 1-888-280-1190 if you have concerns.

"The prior authorization is taking too long"

Solution: Contact your prescriber's office to check submission status. If urgent, request expedited review and have your doctor available for peer-to-peer discussion.

"CVS Specialty says my insurance isn't active"

Solution: Verify your Aetna member ID and effective dates. Contact Aetna member services if there are coverage gaps.

"I can't afford the copay/coinsurance"

Solution: Ask CVS Specialty about manufacturer assistance programs during enrollment. Counterforce Health can also help identify additional financial resources and appeal strategies for high out-of-pocket costs.

FAQ: Most Asked Questions

Q: How long does Aetna prior authorization take for Emflaza in Georgia? A: Standard reviews take up to 30 days for pre-service requests. Expedited reviews for urgent cases can be completed within 72 hours.

Q: What if Emflaza isn't on my Aetna formulary? A: You can request a formulary exception by having your doctor submit documentation showing medical necessity and that formulary alternatives aren't appropriate.

Q: Can I request an expedited appeal in Georgia? A: Yes, both Aetna internal appeals and Georgia external reviews offer expedited timelines (typically 72 hours) for urgent medical situations.

Q: Does step therapy apply if my child tried steroids in another state? A: Yes, documented steroid trials from any location should count toward step therapy requirements. Ensure all medical records are included in your PA submission.

Q: What happens if the external review in Georgia rules against Aetna? A: The decision is binding on Aetna by Georgia law. They must cover the treatment as determined by the external reviewer.

Q: Can I use manufacturer copay cards with Aetna? A: Yes, for most commercial Aetna plans. However, copay cards typically cannot be used with Medicare or Medicaid plans.

From our advocates: We've seen families succeed by being proactive about documentation. One family gathered all their child's steroid trial records before the first denial, including weight charts and behavioral notes from school. When they appealed, they had everything ready and won approval within the first internal review. The key was showing specific, measurable impacts from prednisone rather than general concerns.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and is not medical advice. Insurance coverage and policies can change. Always verify current requirements with Aetna and consult your healthcare provider for medical decisions. For personalized assistance with insurance appeals, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298.

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