By Counterforce Health Team in Retevmo (selpercatinib) —

Get Retevmo (Selpercatinib) Approved by Aetna CVS Health in California: Complete Guide to Prior Authorization, Appeals & Timeline

Answer Box: Your Fastest Path to Retevmo Coverage

Retevmo (selpercatinib) requires prior authorization from Aetna CVS Health in California. To get approved fastest: (1) Ensure RET alteration testing via FDA-approved methods like FoundationOne CDx is documented, (2) Have your oncologist submit the PA with complete clinical records through CVS Specialty's portal, and (3) If denied, file an internal appeal within 180 days, then request California's Independent Medical Review (IMR) for a binding decision. Standard PA decisions take up to 30 days; expedited reviews complete within 72 hours for urgent cases.

Start today: Contact your oncologist to initiate the prior authorization process and verify your RET testing results are complete.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timeline & Urgency
  4. PA Criteria & Requirements
  5. Understanding Costs
  6. Denials & Appeals
  7. Renewal Requirements
  8. Specialty Pharmacy
  9. Troubleshooting
  10. FAQ

Coverage Basics

Is Retevmo Covered by Aetna CVS Health?

Retevmo (selpercatinib) is typically covered by Aetna CVS Health plans but requires prior authorization and is classified as a specialty medication. The drug is placed on higher formulary tiers (often Tier 4 or Specialty), meaning higher patient cost-sharing applies.

Which Plans Include Coverage?

Most Aetna commercial plans, Medicare Advantage, and Medicaid managed care plans include Retevmo on their specialty formularies. However, coverage specifics vary by employer group and regional plan design. Always verify your specific plan's formulary through the Aetna member portal or by calling member services.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before coverage PA criteria documents Aetna Precertification List
Formulary Tier Specialty/Tier 4 Plan formulary guide Plan documents
Quantity Limits 60 tablets per 30 days PA approval letter CVS Caremark policies
Specialty Pharmacy CVS Specialty required Prescription transfer notice CVS Specialty
RET Testing FDA-approved test required Lab report Clinical documentation

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Confirm RET Testing (Patient + Oncologist)
  2. Gather Clinical Documentation (Oncologist)
    • Complete medical records, diagnosis with ICD-10 codes
    • Prior treatment history and outcomes
    • Timeline: 1-2 days to compile
  3. Submit PA Request (Oncologist/Staff)
    • Submit through CVS Caremark provider portal or fax
    • Include all required documentation
    • Timeline: Same day submission possible
  4. Track Status (Patient + Clinic)
    • Monitor via provider portal or member services
    • Timeline: Decision within 14 calendar days (standard)
  5. Prescription Fulfillment (If Approved)
    • CVS Specialty Pharmacy contacts patient
    • Timeline: 1-3 days for first fill coordination
  6. Appeal if Denied (Patient + Oncologist)
    • File internal appeal within 180 days
    • Timeline: 30 days for standard appeal decision
  7. IMR if Needed (Patient)
    • Request Independent Medical Review through California DMHC
    • Timeline: 45 days for standard IMR decision

Timeline & Urgency

Standard Timeline

  • PA Decision: Up to 30 days from complete submission
  • CVS Specialty Processing: 1-3 business days after approval
  • First Fill: 2-5 days from CVS Specialty contact

Expedited/Urgent Timeline

  • Urgent PA: Decision within 72 hours when delay could harm health
  • Expedited Appeal: 72 hours or less for urgent situations
  • Expedited IMR: 7 days or less (often within 72 hours)
Tip: If your condition is rapidly progressing or you're experiencing delays in current treatment, request expedited review. Your oncologist must document the urgent medical need.

PA Criteria & Requirements

Essential Documentation for Approval

Clinical Requirements:

  • RET fusion-positive NSCLC, RET-mutant medullary thyroid cancer, or RET fusion-positive thyroid cancer diagnosis
  • ICD-10 codes matching FDA-approved indications
  • FDA-approved RET alteration test results (FoundationOne CDx, Guardant360 CDx, or equivalent)
  • Oncology or hematology prescriber specialty confirmation

Medical History:

  • Complete treatment history for advanced/metastatic disease
  • Documentation of prior therapy outcomes (if applicable)
  • Contraindications to alternative treatments (when relevant)

Safety Monitoring Plan:

  • Baseline labs including liver function tests
  • EKG and QTc interval assessment
  • Blood pressure monitoring plan

Clinician Corner: Medical Necessity Letter Checklist

When preparing the medical necessity letter, include:

  • Problem Statement: Patient's specific RET-altered cancer diagnosis
  • Prior Treatments: Document previous therapies and outcomes
  • Clinical Rationale: Why selpercatinib is optimal for this patient
  • Guideline Support: Reference FDA labeling and NCCN guidelines
  • Monitoring Plan: Safety assessments and follow-up schedule

For templates and examples, Counterforce Health provides evidence-backed appeal resources that help turn insurance denials into targeted, successful appeals by aligning clinical documentation with payer-specific requirements.

Understanding Costs

Typical Patient Costs

  • Specialty Tier Copay: Often 25-50% coinsurance
  • California Oral Cancer Drug Cap: Some plans limit copays to $250-$300 per 30-day supply
  • Deductible: May apply before copay/coinsurance

Cost Reduction Options

  • Manufacturer Copay Card: Available for commercially insured patients
  • Patient Assistance Programs: Income-based support through Eli Lilly
  • Foundation Grants: Organizations like CancerCare offer medication assistance
Note: Some Aetna plans use copay accumulator programs, meaning manufacturer assistance may not count toward your deductible or out-of-pocket maximum.

Denials & Appeals

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Missing RET testing Submit FDA-approved test results Lab report with RET alteration confirmed
Wrong tumor type Clarify FDA-approved indication Pathology report with correct diagnosis
Step therapy required Document contraindications to alternatives Clinical notes explaining why alternatives inappropriate
"Experimental" claim Reference FDA approval FDA labeling and approval letter

California Appeals Process

Internal Appeal (Aetna):

  • File within 180 days of denial notice
  • Submit online, phone (1-866-235-5660), mail, or fax
  • Include additional clinical documentation
  • Decision within 30 days (72 hours if expedited)

Independent Medical Review (IMR):

  • Available through California DMHC after internal appeal
  • File within 180 days of final adverse determination
  • Binding decision on the insurer
  • No cost to patient
  • Apply online at healthhelp.ca.gov
California Success Rates: IMR overturn rates for oncology drug denials exceed 50%, often reaching 60-70% for cases with strong clinical documentation.

Appeals Playbook for California

  1. Gather Evidence: Medical records, RET testing, treatment history
  2. File Internal Appeal: Use Aetna's California grievance process
  3. Prepare for IMR: If internal appeal denied, immediately prepare IMR application
  4. Get Help: Contact DMHC Help Center (888-466-2219) for assistance

Renewal Requirements

When to Reauthorize

Aetna typically requires reauthorization every 6-12 months, depending on your specific plan and clinical circumstances.

Required Documentation for Renewal

  • Disease Status: Recent imaging showing stable disease or response
  • Safety Monitoring: Current lab results (liver function, blood pressure)
  • Tolerability: Documentation of adverse events and management
  • Continued Indication: Confirmation of ongoing RET-positive status

Monitoring Requirements

  • Liver enzymes: Every 2 weeks for first 3 months, then monthly
  • Blood pressure: Weekly initially, then monthly
  • QT interval: Baseline and periodic EKGs
  • Disease assessment: Imaging every 2-3 months

Specialty Pharmacy

Why CVS Specialty?

Aetna requires Retevmo to be dispensed through CVS Specialty Pharmacy due to:

  • Complex handling requirements
  • Patient education needs
  • Coordinated care management
  • Insurance billing integration

What to Expect

  • CVS Specialty will contact you after PA approval
  • Medication shipped directly to your home
  • Clinical pharmacist consultation included
  • Refill coordination and adherence monitoring

Troubleshooting

Common Issues & Solutions

Portal Access Problems:

  • Reset password through Aetna member portal
  • Contact member services for technical support
  • Use alternative submission methods (fax, phone)

Missing Documentation:

  • Request clinical notes from all treating physicians
  • Ensure RET testing lab report includes FDA-approved test identification
  • Verify ICD-10 codes match FDA-approved indications

Delayed Decisions:

  • Contact member services to check status
  • Request expedited review if clinically appropriate
  • Consider peer-to-peer review request

When to Escalate

Contact California regulators if:

  • Appeals deadlines not met by Aetna
  • Improper denial of expedited review
  • Failure to honor IMR decision

DMHC Help Center: 888-466-2219
File complaint online: healthhelp.ca.gov

FAQ

How long does Aetna CVS Health PA take in California? Standard prior authorization decisions are made within 30 days of complete submission. Expedited reviews for urgent situations are completed within 72 hours.

What if Retevmo is non-formulary on my plan? You can request a formulary exception with clinical justification. If denied, file an internal appeal and potentially an IMR through California DMHC.

Can I request an expedited appeal? Yes, if delay in treatment could seriously harm your health. Your oncologist must document the urgent medical need in the request.

Does step therapy apply if I failed treatments outside California? Prior treatment failures from any location should count toward step therapy requirements. Include complete medical records from all treating facilities.

What happens if I move during treatment? Contact Aetna member services immediately to ensure continued coverage. California IMR rights may not apply if you move to another state.

How much will Retevmo cost me? Costs vary by plan design. Specialty tier medications typically have 25-50% coinsurance. California's oral cancer drug cap may limit costs to $250-$300 per month on some plans.

Can my family doctor prescribe Retevmo? Aetna typically requires prescription by an oncologist or hematologist specializing in cancer care.

What if CVS Specialty is out of network for me? CVS Specialty is the designated specialty pharmacy for Aetna CVS Health. Contact member services if you have concerns about network status.

From Our Advocates

We've seen California patients successfully overturn Retevmo denials by ensuring their RET testing documentation clearly identifies the FDA-approved companion diagnostic used and includes the specific RET alteration details. One common issue is when labs report "RET positive" without specifying the exact fusion or mutation type—this often leads to requests for additional testing that can delay approval by weeks.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Our platform identifies denial reasons and drafts point-by-point rebuttals aligned to each plan's specific rules, using the right clinical evidence and procedural requirements to maximize approval success.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for specific coverage details. Coverage policies and requirements may change. For official guidance on California insurance appeals, contact the Department of Managed Health Care at 888-466-2219 or visit healthhelp.ca.gov.

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