By Counterforce Health Team in Trikafta (elexacaftor/tezacaftor/ivacaftor) —

Get Trikafta Covered by Aetna CVS Health in Florida: Complete Prior Authorization Guide with Forms and Appeals

Answer Box: Getting Trikafta Covered by Aetna CVS Health in Florida

Quick Start: Trikafta requires prior authorization from Aetna CVS Health with CFTR genotype documentation. Submit requests via CoverMyMeds or fax to 855-799-2554 with genetic testing results, baseline liver function tests, and clinical notes. Standard approval takes 24 hours; appeals must be filed within 180 days. If denied, Florida offers external review through the Department of Financial Services (1-877-693-5236).

First Step Today: Verify your CFTR genotype is documented and request baseline labs if not already completed.

Table of Contents

Coverage Requirements at a Glance

Requirement Details Documentation Needed
Prior Authorization Required for all Trikafta prescriptions PA form with clinical notes
Age Requirement 2 years or older Date of birth verification
CFTR Genotype ≥1 F508del or responsive mutation Genetic testing results
Prescriber Pulmonologist or specialist Provider credentials
Baseline Labs Liver function tests Recent ALT/AST values
Diagnosis Confirmed cystic fibrosis ICD-10 codes (E84.x)
Appeal Deadline 180 days from denial Denial letter with date

Sources: Aetna Medicaid Policy, CVS Caremark PA Guidelines

Step-by-Step: Fastest Path to Approval

1. Verify CFTR Genotype Documentation

Who: Patient/clinic coordinator
What: Confirm genetic testing shows F508del or another responsive mutation
Timeline: Same day if already tested

2. Obtain Baseline Liver Function Tests

Who: Prescribing physician
What: Order ALT, AST, and bilirubin if not done within 30 days
Timeline: 1-2 days for results

3. Complete Prior Authorization Request

Who: Healthcare provider
What: Submit via CoverMyMeds or fax to 855-799-2554
Timeline: 24 hours for standard review
Required: PA form, genetic testing, labs, clinical notes, ICD-10 diagnosis

4. Enroll with CVS Specialty Pharmacy

Who: Patient/provider
What: Complete CF Oral Therapies enrollment form
Timeline: 2-3 business days after approval

5. Track Authorization Status

Who: Patient/clinic
What: Call Aetna at 1-855-240-0535 for status updates
Timeline: Check after 24-48 hours if no response

Required Forms and Submission Methods

Primary Submission Channels

Electronic Prior Authorization (Fastest)

Fax Submission

  • Aetna Better Health Florida: 855-799-2554
  • Include cover sheet with member ID and provider NPI
  • Confirm receipt within 24 hours

Phone Authorization

  • Number: 1-855-240-0535
  • Hours: Monday-Friday, 8 AM-6 PM Central
  • Use for urgent requests or status checks

Mail (Slowest Option)

  • Medical Exception Unit
  • 1300 East Campbell Road
  • Richardson, TX 75081

Required Documentation Checklist

✓ Completed PA request form with provider signature (stamps not accepted)
✓ CFTR genotype testing results showing responsive mutation
✓ Baseline liver function tests (ALT, AST, bilirubin)
✓ Clinical notes documenting cystic fibrosis diagnosis
✓ ICD-10 diagnosis codes (typically E84.0 for pulmonary CF)
✓ Insurance cards (front and back copies)
✓ Previous therapy failures (if applicable)

Tip: Incomplete submissions are automatically returned, adding 5-7 days to processing time. Double-check all required fields before submission.

CVS Specialty Pharmacy Enrollment

Once Aetna approves your Trikafta prior authorization, you'll need to enroll with CVS Specialty Pharmacy for fulfillment.

Enrollment Process

  1. Download the CF enrollment form: Cystic Fibrosis Oral Therapies form
  2. Complete patient information: Demographics, insurance details, prescriber information
  3. Submit via multiple channels:
  4. Create patient account: Visit CVS Specialty to manage prescriptions and deliveries

Transfer from Another Pharmacy

If you're currently getting Trikafta elsewhere, CVS Specialty can coordinate the transfer. Call 1-800-237-2767 with your current pharmacy information and prescription details.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
"No CFTR genotype documented" Submit genetic testing results Lab report showing F508del or responsive mutation
"Baseline labs missing" Order and submit liver function tests ALT, AST, bilirubin within 30 days
"Step therapy required" Request exception with medical necessity Prior therapy failures or contraindications
"Quantity limits exceeded" Justify dosing with clinical notes Provider letter explaining dosing rationale
"Not medically necessary" Submit comprehensive clinical documentation Specialist letter, guidelines, treatment goals

Clinician Corner: Medical Necessity Letter

When drafting appeals, include these key elements:

Clinical Rationale

  • Confirmed CF diagnosis with CFTR mutation
  • Current symptoms and disease progression
  • Treatment goals (lung function, nutritional status)

Evidence Base

  • FDA labeling for approved mutations
  • CF Foundation guidelines for CFTR modulators
  • Peer-reviewed studies supporting efficacy

Monitoring Plan

  • Liver function test schedule
  • Pulmonary function monitoring
  • Adverse event management

Appeals Process in Florida

If your initial prior authorization is denied, Florida law provides multiple appeal levels.

Internal Appeal (Level 1)

Timeline: File within 180 days of denial
Processing: 30 days (72 hours if expedited)
Submission:

  • Online via Aetna provider portal
  • Fax: Include denial letter and supporting documentation
  • Phone: 1-855-240-0535 for expedited requests

Required Documents:

  • Original denial letter
  • Completed appeal form
  • Additional clinical evidence
  • Provider attestation letter

External Review (Level 2)

If the internal appeal is unsuccessful, Florida offers independent external review through qualified medical professionals.

Timeline: Request within 4 months of final internal denial
Processing: Standard external review within 45 days; expedited within 72 hours
Contact: Florida Department of Financial Services
Phone: 1-877-693-5236
Cost: Free to consumer

The external reviewer's decision is binding on Aetna and cannot be overturned.

Note: For urgent situations where waiting could harm your health, you can request expedited review at both levels simultaneously.

Contact Numbers and Support

Aetna Member Services

  • General inquiries: 1-800-245-1206
  • Prior authorization: 1-855-240-0535
  • Appeals: 1-877-858-6507
  • TTY: 800-628-3323

Florida State Resources

  • Insurance assistance: 1-877-693-5236 (FL Dept. Financial Services)
  • Medicaid fair hearings: 1-877-254-1055
  • Consumer complaints: Submit online at MyFloridaCFO.com

CVS Specialty Pharmacy

  • Enrollment: 1-800-237-2767
  • Customer service: 1-800-237-2767
  • Hours: Monday-Friday, business hours

When calling, have your member ID, prescription information, and denial letters readily available.

Patient Assistance Programs

Vertex Patient Services

  • Phone: 1-877-752-5933
  • Coverage: Copay assistance, free drug programs
  • Eligibility: Income-based for uninsured/underinsured patients

CF Foundation Compass Program

  • Phone: 1-844-COMPASS (1-844-266-7277)
  • Services: Insurance navigation, appeals assistance
  • Website: cff.org/compass

Florida Medicaid

If you're eligible for Florida Medicaid, Trikafta is covered under the state formulary with prior authorization. Contact Aetna Better Health at 1-800-441-5501 for Medicaid-specific guidance.

Counterforce Health specializes in turning insurance denials into successful appeals by creating evidence-backed, payer-specific rebuttal letters. Their platform analyzes denial reasons and drafts targeted appeals using the right clinical documentation and policy citations, significantly improving approval rates for complex specialty medications like Trikafta.

FAQ

How long does Aetna prior authorization take for Trikafta in Florida? Standard review is completed within 24 hours of receiving complete documentation. Expedited requests for urgent medical situations are processed within 72 hours.

What if Trikafta isn't on my Aetna formulary? Request a formulary exception with your prior authorization. Include clinical documentation showing medical necessity and any failures with formulary alternatives.

Can I appeal if I was stable on Trikafta with previous insurance? Yes. Florida's step therapy exemption law protects patients who were stable on a medication within the previous 90 days, even if it was covered by a different insurer.

What CFTR mutations qualify for Trikafta coverage? Aetna covers Trikafta for patients with at least one F508del mutation or other FDA-approved responsive mutations including G551D, G1244E, G1349D, G178R, G551S, S1251N, S1255P, S549N, S549R, 711+3A→G, and E831X.

How much will I pay for Trikafta with Aetna? Your cost depends on your specific plan's specialty tier copay. Many patients qualify for Vertex's copay assistance program, which can reduce out-of-pocket costs significantly.

What if my doctor isn't a pulmonologist? While Aetna prefers pulmonologist prescribing, they may accept prescriptions from other specialists with appropriate CF expertise. Include the prescriber's credentials and CF treatment experience in your PA request.

Can I get expedited approval if I'm hospitalized? Yes. Expedited prior authorization is available for urgent medical situations. Your provider should clearly document why waiting 24-48 hours would be harmful to your health.

What happens if my appeal is denied? After exhausting Aetna's internal appeals, you can request external review through Florida's Department of Financial Services. This independent review is free and the decision is binding on Aetna.

This article provides educational information about insurance coverage processes and should not be considered medical advice. Coverage decisions depend on individual policy terms and medical circumstances. For personalized guidance, consult with your healthcare provider and insurance representative.

Sources & Further Reading

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