By Counterforce Health Team in Retevmo (selpercatinib) —

How Long Does It Take to Get Retevmo (selpercatinib) Approved by Aetna (CVS Health) in Florida? Timeline & Milestones

Answer Box: What to Expect

Getting Retevmo (selpercatinib) approved by Aetna (CVS Health) in Florida typically takes 14 calendar days for standard prior authorization, or 72 hours for expedited requests. The process requires documented RET alteration testing via FDA-approved companion diagnostics, complete clinical records, and submission through CVS Specialty Pharmacy. Your oncologist submits the prior authorization request with genetic testing results and treatment history. If denied, Florida law provides 180 days to appeal internally, then 120 days for external review through the Florida Department of Financial Services.

First step today: Ensure your RET fusion/mutation testing is complete and documented in your medical record.

Table of Contents

  1. What Affects Retevmo Approval Timing
  2. Pre-Submission Preparation (0-2 Days)
  3. Submission to Initial Review (1-5 Days)
  4. Additional Information Requests (1-7 Days)
  5. Decision Window & Outcomes
  6. If Denied: Appeal Timeline
  7. Renewal Cycles
  8. Timeline Visual & Milestones
  9. Time-Saving Tips
  10. Common Denial Reasons & Solutions
  11. FAQ

What Affects Retevmo Approval Timing

Several factors influence how quickly Aetna (CVS Health) processes your Retevmo (selpercatinib) prior authorization in Florida:

Benefit Type & Plan Design

  • Commercial plans: Standard 14-day review period
  • Medicare Advantage: Same 14-day timeline, with expedited 72-hour option for urgent cases
  • Medicaid managed care: Follows Florida's 72-hour urgent review requirement

Clinical Documentation Completeness Your approval speed depends heavily on having complete documentation upfront:

  • RET alteration testing results from FDA-approved companion diagnostic (Oncomine Dx Target Test)
  • Complete treatment history and prior therapy failures
  • ICD-10 diagnosis codes matching FDA-approved indications
  • Prescriber specialty confirmation (oncology/hematology required)

Formulary Status Retevmo requires prior authorization on all Aetna (CVS Health) formularies, with quantity limits of 60 tablets per 30 days. The drug sits on specialty tiers, requiring dispensing through CVS Specialty Pharmacy.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist:

✓ RET Testing Results: Laboratory report confirming RET fusion (NSCLC/thyroid) or RET mutation (medullary thyroid cancer) using FDA-approved companion diagnostic
✓ Clinical Notes: Oncologist's notes with diagnosis, staging, and treatment rationale
✓ Prior Therapy History: Complete list of previous treatments, dates, and outcomes
✓ Insurance Verification: Current Aetna (CVS Health) member ID and benefit details
✓ Prescriber Information: Oncologist NPI, specialty certification, contact details

Coding Requirements:

  • Primary diagnosis with appropriate ICD-10 code
  • Confirm prescriber specialty matches payer requirements
  • Verify patient meets FDA age requirements (2+ years for Retevmo)
Tip: Have your oncologist's office verify benefits and formulary status before submission to avoid delays.

Submission to Initial Review (1-5 Days)

How Aetna (CVS Health) Processes Retevmo Requests:

Your oncologist submits the prior authorization through CVS Specialty Pharmacy's provider portal or by fax (1-800-323-2445). The initial review checks:

  1. Member eligibility and active coverage
  2. Prescriber credentials (oncology specialty required)
  3. Clinical indication matching FDA-approved uses
  4. Required testing documentation present

Florida-Specific Timeline Rules: Standard prior authorization decisions must be made within 14 calendar days of receiving complete information. For urgent requests where delay could seriously jeopardize health, Florida law requires decisions within 72 hours.

What Triggers Expedited Review:

  • Life-threatening condition requiring immediate treatment
  • Risk of serious adverse health consequences from delay
  • Physician attestation of clinical urgency

Additional Information Requests (1-7 Days)

If your initial submission lacks required documentation, Aetna (CVS Health) will request additional information. Common requests include:

Missing Clinical Details:

  • Specific RET alteration subtype and testing method
  • Prior therapy start/stop dates and reason for discontinuation
  • Current performance status and disease staging

Documentation Gaps:

  • Laboratory reports not clearly showing RET positivity
  • Incomplete treatment history
  • Missing prescriber specialty verification

How to Respond Quickly:

  • Use CVS Specialty's provider portal for fastest submission
  • Include all requested items in a single response
  • Have your care team follow up within 24-48 hours

The review timeline resets when new information is submitted, so comprehensive responses prevent multiple delay cycles.

Decision Window & Outcomes

Typical Approval Outcomes:

Full Approval (60-70% of cases): Coverage approved for up to 12 months with standard quantity limits

Conditional Approval: May require step therapy completion or specific monitoring protocols

Denial: Most commonly due to insufficient RET testing documentation or non-FDA indication use

Reading Your Approval Letter:

  • Note the approval duration (typically 12 months)
  • Check quantity limits and dispensing restrictions
  • Verify CVS Specialty is listed as the required pharmacy
  • Save the approval reference number for future use

If Denied: Appeal Timeline

Florida provides robust appeal rights for Aetna (CVS Health) members facing Retevmo denials:

Internal Appeals (Level 1):

  • Deadline: 180 days from denial notice
  • Decision timeline: 30 days for pre-authorization appeals
  • Expedited option: 72 hours for urgent cases

Internal Appeals (Level 2):

  • Deadline: 60 days from Level 1 denial
  • Decision timeline: Same as Level 1 (30 days standard, 72 hours expedited)

External Review:

  • Deadline: 120 days from final internal denial
  • Reviewer: Independent Review Organization contracted by Florida Department of Financial Services
  • Decision timeline: 30-45 days (3-5 days for expedited)
  • Cost: Free to members
Note: External review decisions are binding on Aetna (CVS Health) and cannot be further appealed by the insurer.

Contact for Florida External Review: Florida Department of Financial Services
Consumer Helpline: 1-877-693-5236
Online complaint portal available at MyFloridaCFO.com

Renewal Cycles

When to Initiate Reauthorization: Start the renewal process 30-45 days before your current approval expires. CVS Specialty typically sends renewal reminders, but tracking expiration dates prevents gaps in coverage.

What Speeds Renewals:

  • Documented treatment response or disease stability
  • No significant adverse events requiring dose modifications
  • Continued RET-positive status (if retesting was performed)
  • Updated clinical notes showing ongoing medical necessity

Renewal Documentation:

  • Current oncologist visit notes
  • Recent imaging or lab results showing treatment response
  • Updated medication list and any dose adjustments
  • Confirmation of continued FDA indication match

Timeline Visual & Milestones

Milestone Timeline Key Actions
Pre-submission 0-2 days Gather RET testing, clinical notes, insurance info
Initial submission Day 1 Oncologist submits PA through CVS Specialty
Benefit verification Days 2-3 Aetna confirms coverage and reviews criteria
Clinical review Days 4-10 Medical team evaluates documentation
Additional info request Days 5-12 If needed, respond within 2-3 days
Final decision Day 14 Approval/denial notification sent
Appeal filing Within 180 days If denied, submit Level 1 appeal
External review Within 120 days After internal appeals exhausted

Time-Saving Tips

Portal Usage: Register for CVS Specialty's patient portal to track your prior authorization status in real-time. The portal provides updates on documentation requests and approval decisions.

Bundled Evidence Strategy: Submit comprehensive documentation upfront rather than responding to multiple information requests. Include:

  • Complete RET testing report with methodology
  • Detailed treatment chronology
  • Relevant clinical guidelines supporting Retevmo use
  • Prescriber attestation of medical necessity

Direct Specialty Routing: Ensure your oncologist submits directly through CVS Specialty rather than routing through primary care or other intermediaries. Specialty pharmacy teams understand oncology prior authorization requirements better.

Peer-to-Peer Preparation: If Aetna (CVS Health) requests peer-to-peer review, have your oncologist prepare with:

  • Patient's complete clinical timeline
  • RET testing methodology and results
  • NCCN or other guideline references
  • Alternative treatment considerations and contraindications

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
Insufficient RET testing Provide FDA-approved companion diagnostic results Oncomine Dx Target Test report or equivalent NGS
Wrong tumor type Confirm FDA indication match Pathology report with specific cancer subtype
Missing prior therapy Document treatment history Medication lists, dates, response/failure reasons
Non-oncology prescriber Transfer to specialist Oncologist or hematologist prescription
Experimental use claim Cite FDA approval and guidelines FDA label, NCCN guidelines, peer-reviewed studies

FAQ

How long does Aetna (CVS Health) prior authorization take for Retevmo in Florida? Standard prior authorization decisions are made within 14 calendar days. Expedited reviews for urgent cases are completed within 72 hours under Florida law.

What if Retevmo is non-formulary on my Aetna plan? Retevmo is covered on Aetna formularies but requires prior authorization and specialty pharmacy dispensing. Non-formulary status would require formulary exception request with clinical justification.

Can I request an expedited appeal if denied? Yes, if waiting for standard appeal review could seriously jeopardize your health. Your oncologist must provide clinical documentation of urgency.

Does step therapy apply to Retevmo? Step therapy requirements vary by plan but are less common for targeted therapies with specific biomarker requirements like RET alterations.

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

How much does Retevmo cost without insurance? Cash prices range from $23,000-$26,000 per 30-day supply. Eli Lilly offers patient assistance programs for eligible patients.

Do I need to use CVS Specialty Pharmacy? Yes, Aetna (CVS Health) requires specialty medications like Retevmo to be dispensed through their contracted specialty pharmacy network, primarily CVS Specialty.

What if I move to another state during treatment? Contact CVS Specialty to update your address and confirm continued coverage under your Aetna plan. Appeal rights and timelines may differ in your new state.

Counterforce Health specializes in turning insurance denials into successful appeals for patients needing specialty medications like Retevmo. Our platform analyzes denial letters and payer policies to create targeted, evidence-backed appeals that align with each insurer's specific requirements. By combining clinical expertise with deep knowledge of payer workflows, we help patients, clinicians, and specialty pharmacies navigate complex prior authorization processes more effectively.

For patients facing Retevmo coverage challenges with Aetna (CVS Health) in Florida, having expert support can make the difference between approval and denial. Counterforce Health provides the specialized knowledge needed to present compelling cases that meet payer expectations while ensuring patients receive their prescribed treatments.

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider regarding treatment decisions and insurance coverage questions. Coverage policies and requirements may change; verify current information with your insurer and healthcare team.

Sources & Further Reading:

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