By Counterforce Health Team in Hetlioz (tasimelteon) —

How Long Does It Take to Get Hetlioz (tasimelteon) Approved by Aetna (CVS Health) in Florida? Complete Timeline Guide

Answer Box: Hetlioz (Tasimelteon) Approval Timeline with Aetna in Florida

Standard timeline: 30-45 days maximum for Aetna (CVS Health) prior authorization decisions in Florida, with urgent cases decided within 72 hours. Most complete submissions are processed within 7-10 days. Key requirements: diagnosis by sleep specialist, documented melatonin failure (≥6 months), and total blindness (for Non-24) or genetic confirmation (for Smith-Magenis syndrome). First step: Have your specialist submit via Aetna's provider portal or specialty PA fax (1-888-267-3277) with complete clinical documentation. If denied, you have 180 days to appeal internally, then 4 months for external review through Florida's Office of Insurance Regulation.

Table of Contents

What Affects Your Timeline

Several factors determine how quickly Aetna (CVS Health) processes your Hetlioz (tasimelteon) prior authorization in Florida:

Benefit Type and Plan Structure

  • Commercial plans: Standard 30-45 day maximum timeline per Aetna's Florida-specific guidance
  • Aetna Better Health Florida (Medicaid): Often 30 days for standard decisions, 48-72 hours for expedited
  • Medicare plans: Federal requirements for 72-hour expedited, 14-day standard decisions

Complexity of Clinical Criteria

Hetlioz requires extensive documentation for two FDA-approved indications:

  • Non-24-Hour Sleep-Wake Disorder: Must prove total blindness and failed melatonin trial
  • Smith-Magenis Syndrome: Requires genetic confirmation and age-appropriate formulation

Completeness of Initial Submission

Aetna reports that over 95% of eligible prior authorizations are approved within 24 hours when complete clinical information is provided upfront.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist

Before your specialist submits, gather:

Diagnosis Documentation

  • Sleep specialist consultation note with ICD-10 codes (G47.24 for Non-24; Q93.88 for SMS)
  • For Non-24: Ophthalmology report confirming total blindness/no light perception
  • For SMS: Genetic testing results (chromosomal microarray or RAI1 mutation)

Sleep Pattern Evidence

  • 2-4 weeks of sleep logs showing free-running pattern (Non-24) or fragmented sleep (SMS)
  • Actigraphy data if available
  • Functional impact documentation (work/school impairment, caregiver burden)

Prior Treatment History

  • Melatonin trial documentation: doses, duration (≥6 months required), outcomes
  • Other sleep medications tried and failed
  • Behavioral interventions attempted
Tip: Use Counterforce Health's platform to organize your clinical evidence and generate targeted appeal letters that align with Aetna's specific criteria.

Verify Plan-Specific Requirements

Contact Aetna at the number on your insurance card to confirm:

  • Current formulary status of Hetlioz vs. generic tasimelteon
  • Step therapy requirements for your specific plan
  • Required specialty (sleep medicine, neurology, or genetics)

Initial Review Process (1-5 Days)

Submission Pathways

Your specialist should submit via the fastest available channel:

Electronic Submission

Specialty Drug Fax

  • Aetna specialty PA fax: 1-888-267-3277
  • Include all supporting documentation in single transmission

Phone for Urgent Cases

  • Call Aetna PA department (number on member ID card)
  • Request expedited review if delay could jeopardize health

What Reviewers Check First

Aetna's initial review focuses on:

  1. Diagnosis match: Does ICD-10 code align with FDA-approved indications?
  2. Specialist credentials: Is prescriber board-certified in appropriate specialty?
  3. Age/formulation appropriateness: Capsules ≥16 years, LQ suspension 3-15 years
  4. Step therapy completion: Adequate melatonin trial documented

Additional Information Requests (1-7 Days)

If Aetna requests additional information, respond within 10 business days to avoid denial. Common requests include:

Clinical Clarifications

  • More detailed sleep logs or actigraphy
  • Specialist letter addressing specific policy criteria
  • Laboratory values or imaging if relevant to diagnosis

Prior Treatment Details

  • Exact dates and doses of melatonin trials
  • Documentation of side effects or treatment failures
  • Rationale for why alternatives aren't suitable
Note: Incomplete responses to information requests are a leading cause of denials. Have your specialist address every point raised in Aetna's request.

Decision Window and Outcomes

Standard Approval Timeline

  • Most cases: 7-10 days for complete submissions
  • Florida maximum: 30-45 days per Aetna's state-specific guidance
  • Expedited requests: Within 72 hours for urgent medical needs

Reading Your Approval Letter

Approved requests will specify:

  • Duration: Typically 12 months for initial approvals
  • Quantity limits: Usually 30-day supply with refills
  • Pharmacy restrictions: Must use CVS Specialty for dispensing
  • Reauthorization date: When to submit renewal request

If Additional Information Is Still Needed

Aetna may issue a "pending" status requiring:

  • Peer-to-peer review between your specialist and Aetna medical director
  • Updated clinical notes within 30 days
  • Clarification of diagnosis or treatment history

If Denied: Appeal Timeline

Florida law provides robust appeal rights for Aetna (CVS Health) members:

Internal Appeals

  • Filing deadline: 180 days from denial notice
  • Decision timeline: 30 days for standard appeals, 72 hours for expedited
  • Required elements: Address each denial reason with supporting evidence

External Review Process

After exhausting internal appeals:

  • Filing deadline: 4 months from final internal denial
  • Process: Independent medical review through Florida's contracted organization
  • Cost: Free to members
  • Decision: Binding on Aetna if overturned

For urgent appeals where delay could seriously jeopardize health, you can request expedited internal and external review simultaneously.

Florida Consumer Assistance

Contact the Florida Department of Financial Services Insurance Consumer Helpline at 1-877-MY-FL-CFO (1-877-693-5236) for assistance with coverage disputes.

Renewal Cycles and Reauthorization

When to Submit Renewal

Submit reauthorization requests 30-45 days before current approval expires to avoid treatment interruption.

Renewal Requirements

For continuation, Aetna typically requires:

  • Ongoing diagnosis: Confirmation that underlying condition persists
  • Clinical benefit: Documentation of improved sleep parameters or functional outcomes
  • Adherence: Confirmation patient is taking medication as prescribed
  • Tolerability: No unacceptable adverse effects

Renewal Timeline

  • Processing: Usually faster than initial approval (7-14 days)
  • Duration: 12-month renewals common for stable patients

Timeline Visual and Milestones

Phase Timeline Key Actions Expected Outcome
Pre-submission 0-2 days Gather documentation, verify benefits Complete PA packet ready
Initial submission Day 1 Submit via portal/fax with all evidence Acknowledgment within 24-48 hours
Initial review Days 2-7 Aetna reviews against policy criteria Approval, denial, or info request
Additional info Days 8-14 Respond to any information requests Complete clinical picture
Final decision Days 15-30 Aetna issues determination Approval letter or denial notice
Appeal (if needed) Days 31-210 File internal appeal with new evidence Overturn or proceed to external review

Time-Saving Tips for Faster Approval

Use Electronic Channels

Submit through Aetna's provider portal rather than fax when possible. Electronic submissions are processed faster and provide tracking capability.

Bundle All Evidence Upfront

Include comprehensive documentation in your initial submission:

  • Complete specialist consultation note
  • All prior treatment records with dates and outcomes
  • Objective sleep data (logs, actigraphy)
  • Genetic or ophthalmology reports as applicable

Request Peer-to-Peer Review Early

If your case is complex, proactively request a peer-to-peer discussion between your specialist and Aetna's medical director rather than waiting for a denial.

Leverage Specialty Pharmacy Support

CVS Specialty can assist with benefits verification and PA coordination, often expediting the process.

At Counterforce Health, we help patients and clinicians streamline the prior authorization process by automatically generating evidence-backed appeals that align with specific payer policies like Aetna's Hetlioz criteria.

Common Denial Reasons and Solutions

Denial Reason How to Overturn
"Insufficient diagnosis documentation" Submit updated specialist note with clear ICD-10 coding and diagnostic criteria
"Step therapy not completed" Provide detailed melatonin trial history with dates, doses, and outcomes
"Age/formulation inappropriate" Confirm FDA labeling compliance and provide weight-based dosing for LQ
"Not medically necessary" Document functional impairment and why alternatives are inadequate
"Experimental/investigational" Cite FDA approval and relevant clinical guidelines

FAQ: Hetlioz Approval Timeline

How long does Aetna (CVS Health) PA take in Florida? Standard decisions within 30-45 days maximum, with most complete submissions processed in 7-10 days. Urgent cases are decided within 72 hours.

What if Hetlioz is non-formulary? Request a formulary exception with medical necessity documentation. Aetna must review exception requests using the same timelines as standard PAs.

Can I request an expedited appeal? Yes, if standard review timing could seriously jeopardize your health. Provide clinical documentation supporting urgency.

Does step therapy apply if I failed melatonin in another state? Yes, prior treatment history from other providers/insurers counts if properly documented with dates, doses, and outcomes.

How do I track my PA status? Use Aetna's member portal or call the number on your insurance card. Your specialist can also check status through the provider portal.

What happens if I need Hetlioz while my PA is pending? Ask about temporary/emergency supplies through CVS Specialty. Some plans provide short-term coverage during PA review.

From our advocates: We've seen cases where patients received approval in as little as 3 days when their sleep specialist submitted comprehensive documentation including detailed sleep logs, genetic testing results, and a thorough melatonin failure history all in the initial request. The key is anticipating what Aetna needs rather than waiting for them to ask.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage policies vary by plan and may change. Always verify current requirements with your insurance provider and consult your healthcare provider about treatment decisions. For assistance with complex prior authorization cases, consider using specialized services like Counterforce Health that help turn insurance denials into successful appeals.

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