By Counterforce Health Team in Taltz (ixekizumab) —

How Long Does It Take to Get Taltz (ixekizumab) Approved by Aetna CVS Health in Michigan? Complete Timeline & Appeals Guide

Answer Box: Getting Taltz (ixekizumab) Covered by Aetna CVS Health in Michigan

Standard approval timeline: up to 14 days. Aetna CVS Health requires prior authorization for Taltz (ixekizumab) in Michigan, with step therapy requirements typically applying. Your fastest path to approval: 1) Have your provider submit a complete precertification form with documented failures of preferred alternatives, 2) Include TB screening and clinical severity documentation, 3) Request expedited review (72-hour decision) if medically urgent. Start today: Call Aetna at 1-866-752-7021 to verify your plan's specific requirements and obtain the current precertification form.

Table of Contents

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required Yes, all Taltz prescriptions need pre-approval Provider must submit PA form Aetna PA List
Step Therapy Must try preferred alternatives first TNF inhibitors, other IL-17/IL-23 agents Aetna PA Requirements
Specialty Tier Typically Tier 4 (highest cost-share) Check your plan's formulary Member Portal
Quantity Limits Yes, specialty quantity restrictions apply May require exception for higher doses Aetna Quantity Limits
Age Requirement 6 years or older for pediatric psoriasis Must meet FDA-approved indications Michigan Medicaid Policy

What Affects Your Approval Timeline

Several factors determine how quickly Aetna CVS Health processes your Taltz (ixekizumab) prior authorization in Michigan:

Documentation Completeness is the biggest factor. Missing clinical notes, incomplete prior therapy records, or outdated TB screening can add 7-14 days to your approval. The precertification form must include your diagnosis with ICD-10 codes, detailed prior treatment history, and current disease severity.

Step Therapy Requirements often extend timelines. For psoriasis, you'll typically need documented failures of topical treatments and preferred biologics like adalimumab (Humira) or other TNF inhibitors. For psoriatic arthritis, methotrexate or other conventional DMARDs must be tried first unless contraindicated.

Specialty Pharmacy Coordination can add processing time. Once approved, Aetna typically routes Taltz through CVS Specialty or other network specialty pharmacies, which requires additional coordination for dispensing and delivery.

Tip: Submit your PA request 2-4 weeks before you need to start treatment to account for potential delays and appeals.

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Requirements (Patient + Provider)

Timeline: Same day
Action: Call Aetna member services at 1-855-676-5772 to confirm Taltz is covered under your specific plan and get current PA requirements.
Documents needed: Insurance card, member ID

2. Gather Required Documentation (Provider)

Timeline: 1-3 days
Action: Collect complete medical records including:

  • Current diagnosis with ICD-10 codes (L40.0 for plaque psoriasis, L40.5+ for psoriatic arthritis)
  • Prior therapy trials and documented failures or contraindications
  • TB screening results (within 6 months)
  • Disease severity assessment and treatment goals
  • Current labs if applicable

3. Complete Prior Authorization Form (Provider)

Timeline: 1 day
Action: Fill out Aetna's Taltz precertification request form completely.
Submit via: Fax to 1-877-269-9916 or electronic portal

4. Aetna Review Process

Timeline: Up to 14 days (standard) or 72 hours (expedited)
What happens: Aetna reviews clinical documentation against their coverage criteria. They may request additional information if anything is missing.

5. Receive Decision

Timeline: Within review period
Outcomes: Approval, denial, or request for more information. Approvals typically include quantity limits and renewal requirements.

6. If Denied: Internal Appeal

Timeline: File within 180 days of denial
Action: Provider or patient can appeal with additional clinical evidence. Standard appeals decided within 30-45 days.

7. Michigan External Review (If Needed)

Timeline: File within 127 days of final internal denial
Action: Request external review through Michigan DIFS. Decisions within 56 days (or 72 hours for urgent cases).

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Step therapy not met" Document failures of preferred alternatives Detailed notes on TNF inhibitor trials, adverse effects, lack of efficacy
"Not medically necessary" Strengthen clinical justification Disease severity scores, photos, quality of life impact, specialist consultation
"Insufficient prior therapy" Expand treatment history Complete medication timeline with dates, doses, duration, outcomes
"Missing TB screening" Submit current screening results TB blood test or chest X-ray within 6 months
"Non-formulary drug" Request formulary exception Statement showing formulary drugs failed or are contraindicated

Appeals Process for Michigan Residents

Internal Appeals with Aetna CVS Health

  • Deadline: 180 days from denial date
  • Timeline: Standard decisions within 30-45 days; expedited within 72 hours
  • How to file: Call 1-855-676-5772 or submit through member portal
  • Required: Denial letter, additional clinical evidence, provider support letter

Michigan External Review

Michigan offers robust external appeal rights through the Department of Insurance and Financial Services (DIFS):

  • Deadline: 127 days from final internal denial (Michigan's specific timeline)
  • Standard review: Up to 56 days for decision
  • Expedited review: 72 hours for urgent cases requiring physician attestation
  • How to file: DIFS External Review portal or call 877-999-6442
  • Cost: Free to patients
  • Decision: Binding on the insurance company
Note: Michigan's 127-day deadline is longer than the federal 120-day standard, giving you extra time to prepare your external appeal.

When dealing with complex prior authorization requirements and appeals, many patients and providers find value in specialized support. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to create point-by-point rebuttals aligned with each plan's specific requirements.

Renewal and Reauthorization Timeline

Taltz approvals are typically granted for 6-12 months. There is no automatic renewal – your provider must proactively request reauthorization before your current approval expires.

Reauthorization Requirements:

  • Updated clinical notes showing ongoing benefit
  • Continued medical necessity documentation
  • Current disease status assessment
  • No changes to step therapy requirements (unless plan updates)

Timeline for Renewal:

  • Start process 30-45 days before expiration
  • Same review timeline as initial authorization (up to 14 days)
  • Appeals process available if renewal is denied

Costs and Patient Assistance

Insurance Coverage: With Aetna CVS Health approval, you'll pay your plan's specialty tier copay or coinsurance, which can range from $50-500+ per month depending on your specific plan.

Manufacturer Support: Eli Lilly offers the Taltz Savings Card for eligible commercially insured patients, potentially reducing copays to as low as $5 per month.

Additional Resources:

  • Patient Advocate Foundation: Financial assistance for specialty medications
  • State pharmaceutical assistance programs in Michigan
  • Specialty pharmacy patient assistance programs

FAQ

How long does Aetna CVS Health prior authorization take for Taltz in Michigan? Standard review takes up to 14 days from submission of complete documentation. Expedited review for urgent cases is completed within 72 hours.

What if Taltz is not on my Aetna formulary? You can request a formulary exception by having your provider submit documentation that formulary alternatives failed or are medically inappropriate. Exception decisions are made within 72 hours of receiving supporting documentation.

Can I appeal if my Taltz prior authorization is denied? Yes. You have 180 days to file an internal appeal with Aetna, then 127 days to request external review through Michigan DIFS if the internal appeal is unsuccessful.

Does step therapy apply if I've tried biologics in another state? Yes, documented treatment failures from other states count toward step therapy requirements. Ensure your Michigan provider has complete records of your prior treatments.

What counts as medical necessity for Taltz? Medical necessity requires documented moderate-to-severe psoriasis or active psoriatic arthritis with inadequate response to conventional therapies, per Aetna's clinical policy.

How do I request expedited review? Check the "urgent" box on the PA form and have your provider document why delay could seriously jeopardize your health. Include a physician letter explaining the urgency.

What happens if my approval expires? Treatment may be interrupted until reauthorization is approved. Start the renewal process 30-45 days early to avoid gaps in coverage.

Can I use CVS Caremark for Taltz if approved? Yes, Aetna typically routes specialty medications like Taltz through CVS Specialty or other network specialty pharmacies for dispensing and delivery.

This information is for educational purposes only and does not constitute medical advice. Coverage policies and requirements may change. Always verify current requirements with your insurance plan and healthcare provider. For assistance with insurance appeals and coverage issues, contact the Michigan Department of Insurance and Financial Services at 877-999-6442 or visit michigan.gov/difs.

Sources & Further Reading

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