By Counterforce Health Team in Turalio (pexidartinib) —

Get Turalio (Pexidartinib) Covered by Aetna CVS Health in Virginia: Decision Tree, Forms & Appeals Guide

Answer Box: Quick Eligibility Check

To get Turalio (pexidartinib) covered by Aetna CVS Health in Virginia, you need: confirmed TGCT diagnosis with imaging, surgical consultation stating "severe morbidity" if resected, REMS program enrollment, and baseline liver function tests. Submit complete prior authorization through CVS Specialty (1-800-237-2767) with all documentation. If denied, Virginia allows external review within 120 days through the State Corporation Commission. Start today: Call CVS Specialty to request the current PA form and enroll in REMS at turaliorems.com.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. Likely Eligible: Document Checklist
  4. Possibly Eligible: Tests to Request
  5. Not Yet Eligible: Alternatives to Discuss
  6. If Denied: Virginia Appeal Path
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & Fixes
  9. FAQ
  10. Sources & Further Reading

How to Use This Decision Tree

This guide helps patients and clinicians navigate Aetna CVS Health's prior authorization process for Turalio (pexidartinib) in Virginia. Work through the eligibility questions below, then follow the appropriate path based on your results.

Before you start, gather:

  • Insurance card and member ID
  • TGCT diagnosis confirmation (pathology, imaging)
  • Surgical consultation notes
  • Recent lab results (liver function tests)
  • List of prior treatments tried
Tip: Aetna CVS Health processes most specialty drug PAs through CVS Specialty pharmacy. Always call their dedicated line at 1-800-237-2767 rather than general member services.

Eligibility Triage: Do You Qualify?

Step 1: Diagnosis Confirmation

Question: Do you have confirmed tenosynovial giant cell tumor (TGCT)?

✅ Yes, if you have:

  • Pathology report confirming TGCT/PVNS
  • MRI or CT imaging showing tumor extent
  • ICD-10 code M12.2 series documented

❌ No, if: Diagnosis is suspected but not confirmed

Step 2: Surgical Assessment

Question: Has surgery been ruled out due to severe morbidity risk?

✅ Yes, if you have:

  • Orthopedic consultation explicitly stating surgery would cause "severe morbidity or functional limitations"
  • Documentation that tumor is not amenable to complete resection
  • Notes explaining why surgical options are inadequate

❌ No, if: Surgery hasn't been evaluated or is still considered feasible

Step 3: Symptom Severity

Question: Do you have documented severe symptoms or functional limitations?

✅ Yes, if you have:

  • Clinical notes describing significant pain, mobility restrictions, or quality-of-life impact
  • Functional assessments showing limitations
  • Progressive symptoms despite conservative management

Step 4: REMS Readiness

Question: Are you eligible for the REMS program?

✅ Yes, if you have:

  • Normal baseline liver function tests (ALT, AST, bilirubin, alkaline phosphatase)
  • No severe liver disease history
  • Ability to comply with monthly monitoring initially

❌ No, if: Severe liver disease or inability to monitor liver function

Likely Eligible: Document Checklist

If you answered "yes" to all eligibility questions, gather these documents for your PA submission:

Required Clinical Documentation

  • PA Form: Current Aetna CVS Health prior authorization form (request from CVS Specialty: 1-800-237-2767)
  • Diagnosis Proof: Pathology report + MRI/CT imaging confirming TGCT
  • Surgical Consultation: Notes explicitly stating surgery would cause "severe morbidity"
  • REMS Enrollment: Completed prescriber and patient forms from turaliorems.com
  • Baseline Labs: Recent liver function tests showing normal values
  • Clinical Summary: Notes documenting symptom severity and functional impact

Submission Process

  1. Complete REMS enrollment first - this prevents ~70% of denials
  2. Submit via CVS Specialty: Phone 1-800-237-2767 or fax 1-855-330-1716
  3. Request acknowledgment within 48 hours
  4. Follow up if no decision in 72 hours
Clinician Corner: Your medical necessity letter should reference FDA prescribing information for "symptomatic TGCT not amenable to surgery causing severe morbidity or functional limitations." Include specific surgical consultation findings and prior treatment history.

Possibly Eligible: Tests to Request

If you're missing key documentation, request these from your healthcare team:

Additional Testing Needed

  • MRI with contrast if only X-rays available
  • Surgical consultation with orthopedic oncologist or experienced orthopedic surgeon
  • Baseline liver panel (ALT, AST, total/direct bilirubin, alkaline phosphatase)
  • Functional assessment documenting specific limitations

Timeline to Reapply

  • Allow 2-4 weeks to gather missing documentation
  • REMS enrollment can begin immediately once liver tests are normal
  • Resubmit PA once all requirements are met

Not Yet Eligible: Alternatives to Discuss

If you don't meet current criteria, discuss these options with your doctor:

Alternative Treatments

  • Surgical evaluation if not yet completed
  • Imatinib or nilotinib (off-label CSF1R inhibitors)
  • Supportive care for symptom management
  • Clinical trial participation if available

Exception Request Strategy

  • Document why standard criteria don't apply to your case
  • Gather additional specialist opinions
  • Consider second opinion for surgical feasibility

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by identifying the specific denial basis and crafting point-by-point rebuttals aligned to each plan's own rules. Their platform can help build stronger exception requests when standard criteria don't fit your situation.

If Denied: Virginia Appeal Path

Virginia provides robust appeal rights through the State Corporation Commission Bureau of Insurance.

Internal Appeals with Aetna CVS Health

Level 1 Appeal (180 days to file):

  • Submit written appeal with all clinical documentation
  • Include new evidence not in original PA
  • Request peer-to-peer review if available
  • Decision timeline: ~30-45 days standard, ≤72 hours expedited

Expedited Appeals:

  • Available if delay would seriously jeopardize health
  • Requires physician certification of urgency
  • Decision within 24-72 hours

Virginia External Review Process

After exhausting internal appeals:

  1. File Form 216-A within 120 days of final internal denial
  2. Submit to: Virginia State Corporation Commission Bureau of Insurance
  3. Timeline: 45 days for standard review, 72 hours for expedited
  4. Cost: Free to consumers
  5. Decision: Binding on insurer if overturned
Note: Virginia's external review process has successfully overturned many specialty drug denials when proper clinical documentation is provided.

Coverage Requirements at a Glance

Requirement Details Where to Verify
Prior Authorization Always required Aetna Precert List
Formulary Status Specialty tier, non-preferred Plan formulary documents
REMS Program Mandatory enrollment turaliorems.com
Step Therapy May be required (plan-specific) CVS Specialty: 1-800-237-2767
Quantity Limits 28-day supply maximum Plan benefit documents
Site of Care CVS Specialty network only CVS Specialty coordination
Diagnosis Confirmed TGCT with ICD-10 M12.2 Clinical documentation
Surgical Assessment "Severe morbidity" consultation Orthopedic specialist notes

Common Denial Reasons & Fixes

Denial Reason How to Overturn
Missing TGCT diagnosis Submit pathology report + imaging studies
Surgical options not addressed Provide consultation stating "severe morbidity" risk
REMS not completed Complete enrollment at turaliorems.com before resubmission
Abnormal liver tests Repeat labs when normal; document baseline values
Insufficient documentation Include comprehensive medical necessity letter
Non-formulary status Request formulary exception with clinical justification
Step therapy required Document failures/intolerances to required medications

Frequently Asked Questions

Q: How long does Aetna CVS Health prior authorization take in Virginia? A: Standard decisions typically take 24-72 hours for complete submissions through CVS Specialty. Incomplete requests may take longer.

Q: What if Turalio is non-formulary on my plan? A: Request a formulary exception through CVS Specialty (1-866-814-5506) with medical necessity documentation. Approved exceptions typically pay at Tier 4 copay levels.

Q: Can I request expedited review? A: Yes, if your physician certifies that delay would seriously jeopardize your health or ability to regain function. Expedited decisions are made within 24-72 hours.

Q: Does Virginia step therapy apply if I failed treatments in another state? A: Yes, prior treatment failures from any state count toward step therapy requirements. Provide documentation of all prior therapies tried.

Q: What happens if my appeal is denied? A: You can file for external review with Virginia's Bureau of Insurance using Form 216-A within 120 days. This independent review is binding on the insurer.

Q: Are there cost assistance programs for Turalio? A: Contact Daiichi Sankyo's patient support program and check with foundations that assist with rare disease medications. Your CVS Specialty pharmacist can provide current program information.

From Our Advocates

"We've seen many Turalio approvals succeed when the surgical consultation clearly states 'severe morbidity' rather than just 'not recommended.' The specific language matters - payers look for explicit statements about functional limitations and quality-of-life impact. REMS enrollment completed upfront also prevents most common denials."

When standard approaches don't work, Counterforce Health helps patients and clinicians build stronger appeals by analyzing the specific denial reasons and crafting targeted responses using the right medical evidence and payer-specific language.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan benefits and medical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For assistance with Virginia insurance issues, contact the State Corporation Commission Bureau of Insurance at 1-877-310-6560.

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