By Counterforce Health Team in Strensiq (asfotase alfa) —

Get Strensiq (asfotase alfa) Covered by Aetna CVS Health in Texas: Complete Prior Authorization & Appeals Guide

Answer Box: Getting Strensiq Covered by Aetna CVS Health in Texas

Strensiq (asfotase alfa) is covered by Aetna CVS Health in Texas for perinatal, infantile, and juvenile-onset hypophosphatasia with prior authorization. Your specialist must submit genetic or biochemical confirmation, clinical documentation, and radiographic evidence. Standard review takes 15 business days; expedited review 72 hours for urgent cases. Start today: Contact your endocrinologist or geneticist to request the 2024 Aetna Strensiq Precertification Form and gather ALPL genetic testing results or alkaline phosphatase levels below normal range.

Table of Contents

  1. Is Strensiq Covered by Aetna CVS Health?
  2. Prior Authorization Requirements
  3. Submission Process and Timeline
  4. Cost and Formulary Information
  5. Common Denial Reasons and Solutions
  6. Appeals Process in Texas
  7. Renewal and Reauthorization
  8. Specialty Pharmacy Requirements
  9. Financial Assistance Options
  10. Frequently Asked Questions

Is Strensiq Covered by Aetna CVS Health?

Yes, Aetna CVS Health covers Strensiq (asfotase alfa) in Texas for patients with confirmed perinatal, infantile, or juvenile-onset hypophosphatasia (HPP). Coverage requires prior authorization and is limited to the only FDA-approved indication for pediatric-onset HPP.

Coverage at a Glance

Requirement Details Where to Find
Prior Authorization Required for all patients Aetna Policy 0901
Formulary Tier Specialty Tier (highest cost-share) Aetna Drug Guide
Step Therapy None required FDA-approved as first-line treatment
Age Restrictions Pediatric-onset only (symptoms before age 18) Aetna Medical Policy
Prescriber Requirements Endocrinologist, geneticist, or metabolic specialist PA form requirements

Counterforce Health helps patients navigate complex prior authorization requirements for specialty medications like Strensiq. Our platform analyzes denial letters and creates targeted, evidence-backed appeals that align with each payer's specific requirements, significantly improving approval rates for rare disease treatments.

Prior Authorization Requirements

Clinical Criteria for Approval

Aetna requires all of the following criteria to be met:

1. Confirmed HPP Diagnosis

  • Genetic confirmation: Pathogenic ALPL gene mutation, OR
  • Biochemical confirmation:
    • Serum alkaline phosphatase below age/gender reference range
    • Elevated TNSALP substrate (serum PLP, urine PEA, or plasma PPi)
    • Radiographic skeletal abnormalities consistent with HPP

2. Disease Onset Documentation

  • Perinatal, infantile, or juvenile-onset HPP only
  • For patients ≥18 years: Clear documentation of symptom onset before age 18

3. Dosing Limits

  • Perinatal/infantile-onset: Maximum 9 mg/kg/week
  • Juvenile-onset: Maximum 6 mg/kg/week

4. Specialist Prescriber

  • Must be prescribed by an endocrinologist, geneticist, or metabolic specialist

Required Documentation Checklist

  • Genetic testing results (ALPL mutation) OR biochemical evidence
  • Serum alkaline phosphatase levels with age-appropriate reference ranges
  • Clinical presentation notes documenting symptom onset
  • Radiographic evidence of skeletal abnormalities
  • ICD-10 diagnosis codes: E83.30, E83.31, E83.32, or E83.39
  • Specialist consultation notes
  • Growth charts and functional assessments (if applicable)

Submission Process and Timeline

Step-by-Step: Fastest Path to Approval

1. Gather Documentation (Patient/Family)

  • Collect all genetic testing, lab results, and imaging studies
  • Request complete medical records from all treating specialists
  • Timeline: 1-2 weeks

2. Complete PA Form (Prescribing Clinic)

3. Submit Request (Clinic Staff)

  • Fax to 1-888-267-3277 with all required attachments
  • Submit via Aetna provider portal (confirm current link)
  • Obtain confirmation number for tracking
  • Timeline: Same day

4. Follow Up (Clinic/Patient)

  • Standard review: 15 business days
  • Expedited review: 72 hours for urgent cases
  • Track status via provider portal or member services
Tip: Mark requests as urgent if treatment delay could worsen bone disease or respiratory function. Include physician attestation of urgency for fastest processing.

Cost and Formulary Information

Specialty Tier Coverage

Strensiq is classified as a Specialty Tier medication, typically requiring:

  • 20-50% coinsurance for most Aetna plans
  • CVS Specialty Pharmacy dispensing requirement
  • Potential out-of-pocket costs of $1,000+ per fill before reaching annual maximums

Plan-Specific Variations

Coverage details vary by plan type:

  • Individual ACA Plans: Subject to essential health benefits requirements
  • Employer Plans: May have different cost-sharing structures
  • Medicare Plans: Follow Medicare Part D specialty drug rules

Note: Aetna is exiting the individual marketplace in Texas effective January 1, 2026. Current individual plan members should explore alternative coverage options during open enrollment.

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
"Adult-onset HPP not covered" Submit pediatric-onset evidence Growth charts, childhood medical records, family history
"Insufficient genetic confirmation" Provide ALPL testing or biochemical proof Genetic counselor report, lab results with reference ranges
"Experimental/investigational" Cite FDA approval and guidelines FDA label, medical society recommendations
"Dosing exceeds guidelines" Justify weight-based calculation Current weight, BSA calculation, specialist rationale
"Lack of medical necessity" Document functional impairment 6-Minute Walk Test, respiratory function, pain scores

Medical Necessity Letter Essentials

Your specialist's letter should include:

  1. Patient-specific clinical presentation with objective measures
  2. Genetic or biochemical confirmation with lab values
  3. Treatment rationale based on FDA labeling and clinical guidelines
  4. Expected outcomes and monitoring plan
  5. Risk of untreated disease progression

Appeals Process in Texas

Internal Appeal Process

Level 1: Standard Internal Appeal

  • Deadline: 180 days from denial date
  • Timeline: 30 days for pre-service requests
  • How to file: Aetna member portal or written request
  • Required: Appeal form, additional clinical evidence, physician support letter

Level 2: Expedited Internal Appeal

  • Timeline: 72 hours for urgent cases
  • Criteria: Treatment delay could jeopardize health
  • Process: Mark as "urgent" and include physician attestation

External Review in Texas

If internal appeals are denied, Texas law provides Independent Review Organization (IRO) review:

Texas External Review Process:

  • Deadline: 4 months from final internal denial
  • Timeline: 20 days for standard review, 5 days for urgent
  • Cost: Paid by Aetna (no cost to patient)
  • Decision: Binding on the insurer

How to Request External Review:

  1. Complete IRO request form (provided with denial letter)
  2. Submit to Texas Department of Insurance
  3. Include all medical records and appeal documentation
  4. Request expedited review if medically urgent
From our advocates: We've seen families successfully overturn Strensiq denials by submitting comprehensive genetic testing results alongside detailed growth charts showing failure to thrive. The key is demonstrating that symptoms began in childhood, even when the diagnosis comes later. One family's appeal was approved after including a pediatric endocrinologist's letter explaining how adult symptoms reflected untreated juvenile-onset HPP.

Texas Resources for Help

  • Texas Department of Insurance: 1-800-252-3439
  • Office of Public Insurance Counsel: 1-877-611-6742
  • Disability Rights Texas: Assistance with appeals and fair hearings
  • IRO Information Line: 1-866-554-4926

Renewal and Reauthorization

Continuation Criteria

Aetna requires reauthorization every 6-12 months with evidence of:

  • Clinical benefit: Improved growth, function, or quality of life measures
  • Adherence: Consistent medication administration
  • Ongoing medical necessity: Continued specialist oversight

Documentation for Renewal

  • Updated functional assessments (6-Minute Walk Test, Timed Up & Go)
  • Growth measurements and bone density studies
  • Specialist evaluation of treatment response
  • Any changes in clinical status or dosing requirements

Specialty Pharmacy Requirements

CVS Specialty Pharmacy

All Strensiq prescriptions must be filled through CVS Specialty Pharmacy for Aetna members:

  • Phone: 1-800-237-2767
  • Process: Automatic transfer from retail pharmacy
  • Delivery: Home delivery with temperature control
  • Support: Clinical pharmacist consultation available

Injection Training and Support

CVS Specialty provides:

  • Injection technique training
  • Sharps disposal containers
  • Side effect monitoring
  • Adherence support programs

Financial Assistance Options

Manufacturer Support

Alexion Access Navigator:

  • Copay assistance programs
  • Patient assistance for uninsured/underinsured
  • Prior authorization support services
  • Website: alexionaccessnavigator.com

Foundation Grants

  • National Organization for Rare Disorders (NORD)
  • HealthWell Foundation
  • Patient Access Network Foundation
  • Hypophosphatasia-specific foundations

State Programs

Texas residents may qualify for:

  • Medicaid (if eligible based on income/disability)
  • CHIP (for children in qualifying families)
  • State pharmaceutical assistance programs

Frequently Asked Questions

Q: How long does Aetna prior authorization take for Strensiq in Texas? A: Standard review takes 15 business days. Expedited review for urgent cases is completed within 72 hours per federal requirements.

Q: What if Strensiq is denied as "experimental"? A: Appeal with FDA approval documentation and cite Aetna's own medical policy recognizing Strensiq for pediatric-onset HPP. Include peer-reviewed efficacy studies.

Q: Can I get Strensiq covered if diagnosed with HPP as an adult? A: Only if you can document that symptoms began before age 18. Adult-onset HPP is not covered by most insurers, including Aetna.

Q: Does step therapy apply to Strensiq? A: No. Strensiq is the only FDA-approved disease-modifying therapy for pediatric-onset HPP, so no alternative treatments are required first.

Q: What happens if I move to another state? A: Coverage continues under the same Aetna plan, but appeal rights and external review processes may differ by state. Verify local regulations.

Q: Can I request a peer-to-peer review? A: Yes. Your specialist can request to speak directly with an Aetna medical director to discuss the clinical rationale for Strensiq therapy.

When navigating complex prior authorization requirements, Counterforce Health provides targeted support by analyzing denial patterns and creating evidence-backed appeals that align with payer-specific criteria, helping families secure coverage for essential rare disease treatments.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and clinical circumstances. Always consult your healthcare provider and insurance carrier for plan-specific requirements. For personalized assistance with prior authorization and appeals, consider consulting with Counterforce Health or other qualified advocacy services.

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