By Counterforce Health Team in Jaypirca (pirtobrutinib) —

Get Jaypirca (Pirtobrutinib) Approved by Aetna CVS Health in Ohio: Complete Prior Authorization Guide

Answer Box: Getting Jaypirca Approved in Ohio

Jaypirca (pirtobrutinib) requires prior authorization from Aetna CVS Health in Ohio. Your oncologist submits the PA through CVS Caremark at 1-800-294-5979 with complete documentation of prior BTK inhibitor failure (and BCL-2 inhibitor for CLL/SLL). Over 95% of properly documented requests are approved within 24-48 hours. If denied, you have 180 days to appeal internally, then request external review through the Ohio Department of Insurance (1-800-686-1526).

First step today: Contact your oncologist to confirm they have all prior treatment records and can submit the PA request immediately.

Table of Contents

  1. Start Here: Verify Your Aetna CVS Health Plan
  2. Required Forms and Documentation
  3. Submission Portals and Contact Information
  4. Prior Authorization Requirements
  5. CVS Specialty Pharmacy Setup
  6. Appeals Process for Ohio Residents
  7. Support Lines and Case Management
  8. Ohio Department of Insurance Resources
  9. Common Denial Reasons and Solutions
  10. FAQ

Start Here: Verify Your Aetna CVS Health Plan

Before pursuing Jaypirca coverage, confirm your specific Aetna plan details:

Check Your Coverage:

  • Log into your Aetna member portal or call the number on your ID card
  • Verify specialty pharmacy benefits are active
  • Confirm your plan includes prescription drug coverage (not all Aetna plans do)

Plan Types That Cover Jaypirca:

  • Commercial employer plans
  • Individual marketplace plans
  • Medicare Advantage plans (Part D coverage)
  • Aetna Better Health Medicaid plans
Note: All Jaypirca prescriptions must be dispensed through CVS Specialty Pharmacy as a mandatory requirement.

Required Forms and Documentation

Coverage at a Glance

Requirement What It Means Where to Find It Timeline
Prior Authorization Required for all prescriptions CVS Caremark: 1-800-294-5979 24-48 hours typical
Specialty Pharmacy CVS Specialty only Fax: 1-866-387-2573 Setup within 1-2 days
Medical Documentation Complete treatment history Your oncologist's records Gather before PA submission
Appeals Deadline 180 days from denial Internal appeal first Standard: 45 days

Medical Necessity Documentation Checklist

Your oncologist must provide:

Diagnosis Requirements:

  • Pathologically confirmed mantle cell lymphoma (MCL) OR chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Disease staging and current status
  • ICD-10 codes (C83.1 for MCL, C91.1 for CLL/SLL)

Prior Treatment Documentation:

  • For MCL: At least two prior lines of systemic therapy, including a BTK inhibitor (Imbruvica, Calquence, or Brukinsa)
  • For CLL/SLL: At least two prior therapies, including both a BTK inhibitor AND a BCL-2 inhibitor (Venclexta)
  • Specific dates of treatment and reasons for discontinuation
  • Documentation of treatment failure or intolerance

Clinical Justification:

  • Current performance status and treatment goals
  • Baseline platelet count and coagulation studies
  • Bleeding risk assessment and mitigation plan
  • Expected treatment duration and monitoring plan

Submission Portals and Contact Information

Primary Contact Numbers

CVS Caremark Prior Authorization:

  • Phone: 1-800-294-5979
  • Fax: 1-866-785-5714
  • Available 7 days/week, 24 hours for urgent requests

CVS Specialty Pharmacy:

  • Prescription Fax: 1-866-387-2573
  • CareTeam Support: 1-855-264-3239 (TTY 711)
  • Hours: Monday-Friday 9 AM to 6 PM ET

Electronic Submission Options

Provider Portal Submission:

  • Aetna providers can submit through the Availity provider website
  • Electronic prescribing is preferred for faster processing
  • CVS Specialty NCPDP ID: 1466033

Prior Authorization Requirements

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient/Clinic)
    • Complete medical records from past 6 months
    • Prior treatment history with specific dates
    • Current lab values and imaging
  2. Submit PA Request (Oncologist)
    • Call 1-800-294-5979 or use provider portal
    • Include all required clinical documentation
    • Request expedited review if clinically urgent
  3. Await Decision (24-48 hours typical)
    • Over 95% of properly documented requests approved
    • Complex cases may take up to 15 business days
    • No response within timeframe = automatic approval
  4. If Approved (Patient)
    • Authorization valid for 12 months
    • Set up CVS Specialty Pharmacy account
    • Coordinate delivery preferences
  5. If Denied (Patient/Clinic)
    • Request peer-to-peer review immediately
    • File internal appeal within 180 days
    • Gather additional supporting documentation

Renewal Requirements

Prior authorizations require renewal every 6-12 months with documentation of:

  • Continued medical necessity and disease status
  • Treatment response through imaging or lab values
  • Tolerability assessment and any dose modifications
  • Evidence of no disease progression
Tip: Submit renewal requests 30-45 days before expiration to avoid treatment interruption.

CVS Specialty Pharmacy Setup

Onboarding Process

Patient Enrollment:

  1. Your doctor sends prescription to CVS Specialty (fax 1-866-387-2573)
  2. CVS Specialty contacts you within 24 hours to set up account
  3. Complete insurance verification and copay assistance enrollment
  4. Choose delivery location (home, work, or CVS pharmacy pickup)

Delivery Options:

  • Free, secure delivery within 48 hours
  • Package tracking available
  • Temperature-controlled shipping for specialty medications
  • Flexible scheduling for delivery

Support Services:

  • Medication training and injection instruction
  • 24/7 pharmacist consultation
  • Copay assistance program coordination
  • Refill reminders and adherence support

Appeals Process for Ohio Residents

Internal Appeals with Aetna CVS Health

Timeline and Process:

  • File within: 180 days of denial notice
  • Standard review: 45 business days for decision
  • Expedited review: 36-72 hours for urgent situations
  • Submission: Aetna provider portal, mail, or fax

Required Documentation:

  • Original denial letter with claim number
  • Complete medical records (minimum 6 months)
  • Physician's statement of medical necessity
  • Clinical guidelines supporting treatment (NCCN, specialty society recommendations)
  • Peer-reviewed studies demonstrating medical need
  • Documentation of failed step therapy treatments

External Review Through Ohio Department of Insurance

When to File:

  • After exhausting Aetna's internal appeal process
  • Within 180 days of final internal denial
  • For medical necessity or clinical judgment denials

Ohio External Review Process:

  • Contact Ohio Department of Insurance: 1-800-686-1526
  • Independent Review Organization (IRO) assigned randomly
  • Standard review: 30 days for decision
  • Expedited review: 72 hours for urgent cases
  • Decision is binding on Aetna

Ohio-Specific Rights:

  • No minimum cost threshold for external review
  • No cost to patient for external review
  • Ohio Department of Insurance can independently determine eligibility
  • IRO decisions are binding on insurers

Support Lines and Case Management

Member Services

  • Aetna Member Services: Number on your ID card
  • Hours: 8 AM – 8 PM ET (Monday-Friday)
  • TTY: 711 for hearing impaired

Specialty Pharmacy Support

  • CVS Specialty CareTeam: 1-855-264-3239
  • Live chat: Available on CVS Specialty website and app
  • Services: Order status, billing questions, medication support

Case Management

For complex cases requiring coordination between multiple providers or insurance issues, request assignment to an Aetna case manager through member services.

Ohio Department of Insurance Resources

Consumer Protection Services

Ohio Department of Insurance Consumer Hotline:

  • Phone: 1-800-686-1526
  • Services: Appeals guidance, external review assistance, complaint filing
  • Online: insurance.ohio.gov

Additional Ohio Resources:

  • UHCAN Ohio: Universal Health Care Action Network provides consumer assistance
  • Ohio Senior Health Insurance Information Program (OSHIIP): For Medicare-related appeals
  • Ohio Department of Medicaid: For Medicaid managed care appeals

Filing Complaints

If you encounter issues with Aetna's appeals process, file a complaint with the Ohio Department of Insurance through their online portal or by calling the consumer hotline.

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
No prior BTK inhibitor documented Provide complete treatment history Medical records showing specific BTK inhibitor use and failure/intolerance
Insufficient clinical justification Submit detailed medical necessity letter Oncologist's statement with clinical rationale and treatment goals
Non-formulary status Request formulary exception Evidence that formulary alternatives are inappropriate or have failed
Step therapy not completed Document contraindications or failures Records showing intolerance or medical reasons to bypass step therapy
Experimental/investigational Cite FDA approval and guidelines FDA labeling, NCCN guidelines, peer-reviewed studies

Scripts for Common Situations

Patient Phone Script for Aetna: "Hello, I'm calling about prior authorization for Jaypirca, generic name pirtobrutinib. My doctor submitted a request on [date]. Can you check the status and let me know what additional information might be needed? My member ID is [number]."

Clinic Staff Script for Peer-to-Peer: "I'm requesting a peer-to-peer review for a Jaypirca prior authorization denial. The patient has relapsed [MCL/CLL] after failing [specific BTK inhibitor]. Can we schedule a call with the medical director to discuss the clinical rationale?"

FAQ

How long does Aetna CVS Health prior authorization take for Jaypirca in Ohio? Most properly documented requests are approved within 24-48 hours. Complex cases may take up to 15 business days.

What if Jaypirca is not on my Aetna formulary? You can request a formulary exception through the same prior authorization process. Your doctor will need to provide medical necessity documentation.

Can I request an expedited appeal in Ohio? Yes, if a delay could seriously jeopardize your health. Expedited appeals receive decisions within 36-72 hours.

Does step therapy apply if I failed BTK inhibitors outside Ohio? No, prior treatment failures from any location count toward meeting step therapy requirements if properly documented.

What happens if my internal appeal is denied? You can request external review through the Ohio Department of Insurance within 180 days. The IRO decision is binding on Aetna.

How much does Jaypirca cost with Aetna coverage? Costs vary by plan, but specialty tier copays typically range from $100-500 per month. Manufacturer copay assistance may be available.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform ingests denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned to each payer's specific requirements, significantly improving approval rates for complex medications like Jaypirca.

Getting Jaypirca approved doesn't have to be overwhelming. With proper documentation and understanding of Aetna's requirements, most patients receive approval quickly. If you encounter denials, Ohio's consumer-friendly external review process provides an additional safety net. Remember to work closely with your oncologist and don't hesitate to contact Counterforce Health if you need assistance crafting a compelling appeal.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for specific guidance regarding your situation. Coverage policies and contact information may change; verify current details with official sources.

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