By Counterforce Health Team in Acthar Gel (repository corticotropin injection) —

How to Get Acthar Gel Covered by Aetna CVS Health in Georgia: Prior Authorization Guide and Appeals Process

Answer Box: Getting Acthar Gel Covered by Aetna in Georgia

Aetna CVS Health only covers Acthar Gel (repository corticotropin injection) for infantile spasms in patients under 2 years old. All other uses require appeals based on medical necessity. Your fastest path: 1) Submit prior authorization with complete failure documentation of corticosteroids, 2) If denied, file internal appeal within 180 days, 3) Request Georgia external review within 60 days of final denial. Start by calling Aetna precertification at (866) 752-7021 or having your provider submit through the Availity portal.

Table of Contents

Why Georgia State Rules Matter

Georgia's insurance regulations provide important protections for Acthar Gel appeals that interact with Aetna's national policies. While Aetna sets the clinical criteria, Georgia law determines your appeal timelines and rights.

Key Georgia protections include:

  • 60-day external review deadline after internal appeal denial
  • Binding external review decisions that Aetna must honor
  • Expedited appeals (72 hours) for urgent medical situations
  • Consumer assistance through the Georgia Department of Insurance

These state protections are crucial because Acthar Gel carries a very high cost (often $30,000+ per vial) and faces strict utilization management from all insurers.

Aetna's Coverage Criteria for Acthar Gel

According to Aetna's clinical policy bulletin, Acthar Gel is considered medically necessary only for infantile spasms in members less than 2 years of age. All other FDA-approved indications are classified as experimental, investigational, or not medically necessary.

Covered indication:

  • Infantile spasms (West syndrome) in patients under 24 months

Non-covered indications (require appeals):

  • Multiple sclerosis exacerbations
  • Rheumatologic conditions (rheumatoid arthritis, psoriatic arthritis)
  • Nephrology conditions (nephrotic syndrome, proteinuria)
  • Dermatologic conditions
  • Allergic states
  • Respiratory diseases
Note: Aetna's restrictive policy conflicts with FDA labeling, which approves Acthar Gel for multiple conditions. This creates appeal opportunities when you can demonstrate medical necessity.

Prior Authorization Requirements

Precertification is mandatory for all Aetna plans in Georgia. Here's what you need to know:

Requirement Details Contact Method
Phone PA (866) 752-7021 Standard requests
Fax PA (888) 267-3277 Document submission
Medicare Part B (866) 503-0857 MA members only
Quantity Limits 35 mL per 21 days Specialty limits policy

Required documentation:

Step-by-Step: Fastest Path to Approval

Step 1: Gather Documentation (Patient + Clinic)

Timeline: 1-2 days
Action: Collect insurance card, prior therapy records, diagnosis confirmation, and recent clinical notes.

Step 2: Submit Prior Authorization (Clinic)

Timeline: Same day
Action: Provider submits PA via Availity portal or fax (888) 267-3277 with complete documentation.

Step 3: Await Initial Decision (Aetna)

Timeline: 30-45 days (standard) or 72 hours (expedited)
Action: Aetna reviews against clinical criteria and quantity limits.

Step 4: File Internal Appeal if Denied (Patient/Clinic)

Timeline: Within 180 days of denial
Action: Submit appeal with medical necessity letter addressing specific denial reasons.

Step 5: Request External Review (Patient)

Timeline: Within 60 days of internal appeal denial
Action: File with Georgia DOI using external review application.

Step 6: Implement Binding Decision (Aetna)

Timeline: 30-45 days for standard external review
Action: Aetna must comply with favorable external review decisions.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Not FDA approved for indication" Cite FDA labeling section FDA Acthar Gel label with relevant indication
"Experimental/investigational" Reference clinical guidelines Peer-reviewed studies, specialty society recommendations
"Corticosteroids not tried first" Document failure/intolerance Medical records showing adverse effects, lack of efficacy
"Quantity exceeds limits" Medical necessity for higher dose Provider letter explaining dosing rationale, patient weight/BSA
"Non-formulary medication" Request formulary exception Comparative effectiveness data vs. alternatives

Appeals Process in Georgia

Internal Appeals with Aetna

Standard Appeals:

  • Deadline: 180 days from denial notice
  • Timeline: Up to 30 days for decision
  • Submission: Online via Availity, fax, or mail

Expedited Appeals:

  • Criteria: Delay would seriously jeopardize health
  • Timeline: 72 hours for decision
  • Process: Same submission methods, mark "URGENT"

Required elements for internal appeals:

  • Original denial letter
  • Medical necessity statement from prescriber
  • Supporting clinical documentation
  • Patient/provider contact information

Peer-to-Peer Review

Request a peer-to-peer review when clinical judgment is questioned. Your prescriber can speak directly with an Aetna medical director to explain the medical necessity.

To request: Call (866) 752-7021 and ask for peer-to-peer review scheduling.

External Review Through Georgia DOI

If Aetna denies your internal appeal, Georgia law provides independent external review through the Department of Insurance.

Key details:

  • Deadline: 60 days from internal appeal denial
  • Cost: Free to consumers
  • Timeline: 45 days for standard review, 72 hours for expedited
  • Decision: Binding on Aetna

How to file:

  1. Contact Georgia DOI Consumer Services: (800) 656-2298
  2. Complete external review application (available on DOI website)
  3. Submit with denial letters and supporting documents
  4. Await assignment to independent medical reviewer

Georgia DOI contact: Office of Commissioner of Insurance and Fire Safety
Administrative Procedure Division
Email: [email protected]

Scripts & Templates for Success

Patient Phone Script for Aetna

"Hello, I'm calling about prior authorization for Acthar Gel for my [condition]. My member ID is [number]. My doctor says this medication is medically necessary because [brief reason]. Can you tell me the status of my request and what additional information you need?"

Medical Necessity Letter Template

Healthcare providers should include these elements:

Patient Information:

  • Full name, DOB, member ID
  • Primary and secondary diagnoses with ICD-10 codes

Clinical Rationale:

  • Specific indication requiring Acthar Gel
  • Previous treatments tried and outcomes
  • Contraindications to standard therapies
  • Expected treatment goals and monitoring plan

Supporting Evidence:

  • FDA labeling references
  • Clinical guideline citations
  • Peer-reviewed literature (if applicable)
  • Provider attestation of medical necessity

Appeal Letter Framework

"I am appealing the denial of Acthar Gel for [patient name] dated [date]. The denial stated [reason], however, this medication is medically necessary because [specific clinical rationale]. Attached documentation demonstrates [list evidence]. I request reconsideration based on the medical evidence provided."

Cost Assistance Programs

Given Acthar Gel's high cost, explore these financial assistance options:

Mallinckrodt Patient Assistance:

  • Acthar Support and Access Program
  • Copay assistance for eligible patients
  • Contact: ActharSupport.com or (888) 435-2284

Foundation Grants:

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Chronic Disease Fund

State Programs:

  • Georgia pharmacy assistance programs (income-based)
  • Medicaid coverage for eligible patients
From our advocates: We've seen patients successfully obtain Acthar Gel coverage after initial denials by thoroughly documenting corticosteroid failures and citing FDA labeling in their appeals. The key is persistence and complete medical documentation. While outcomes vary, many appeals succeed when the medical necessity is clearly established.

FAQ: Acthar Gel Coverage in Georgia

How long does Aetna prior authorization take in Georgia?
Standard PA decisions take 30-45 days. Expedited requests (when delay poses health risks) are decided within 72 hours.

What if Acthar Gel is non-formulary on my plan?
You can request a formulary exception with documentation showing medical necessity and failure of preferred alternatives.

Can I get expedited appeals for Acthar Gel?
Yes, if your doctor certifies that delay would seriously jeopardize your health or ability to regain maximum function.

Does step therapy apply if I failed corticosteroids in another state?
Yes, documented failures from other states count toward step therapy requirements. Provide complete medical records.

What happens if my external review is denied?
External review decisions are final for the administrative process. Further options may include legal action, but this is rare.

How do I prove medical necessity for off-label uses?
Cite FDA labeling, clinical guidelines, peer-reviewed studies, and document why standard treatments are inappropriate for your specific case.

Can my doctor request a peer-to-peer review?
Yes, prescribers can request to speak directly with Aetna medical directors to explain clinical rationale.

What if I need Acthar Gel while my appeal is pending?
Ask your doctor to request expedited review if the delay poses health risks. Some patients may need to pay out-of-pocket temporarily.

When Coverage Gets Complex

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Acthar Gel. Their platform analyzes denial letters, identifies specific coverage criteria, and generates evidence-backed appeals that address payer requirements point-by-point. For patients and providers struggling with repeated denials, professional appeal assistance can significantly improve approval rates by ensuring all clinical and procedural requirements are properly addressed.

The appeals process for high-cost specialty medications requires careful attention to both clinical evidence and procedural requirements. Georgia's consumer protections provide important safeguards, but success often depends on thorough documentation and persistence through multiple appeal levels.

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 terms and clinical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For official Georgia insurance regulations and consumer assistance, contact the Georgia Department of Insurance at (800) 656-2298.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.