By Counterforce Health Team in Alecensa (alectinib) —

How to Get Alecensa (alectinib) Covered by Aetna CVS Health in Michigan: Complete Guide to Prior Authorization and Appeals

Quick Answer: Getting Alecensa (alectinib) Covered by Aetna CVS Health in Michigan

Aetna CVS Health requires prior authorization for Alecensa (alectinib), an ALK inhibitor for non-small cell lung cancer. Your fastest path to approval: Submit the PA request with ALK-positive test results, prior therapy documentation, and medical necessity letter through CVS Caremark's electronic portal or fax to 1-888-267-3277. If denied, you have 60 days to appeal internally, then 127 days to file an external review with Michigan DIFS. Start by verifying your plan's formulary status and gathering your ALK testing results today.

Table of Contents

  1. Start Here: Verify Your Plan and Find Forms
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Electronic Options
  4. Fax and Mail Submission Details
  5. Specialty Pharmacy Setup
  6. Support Lines and Contact Information
  7. Appeals Process: Internal and External
  8. Michigan DIFS External Review
  9. Common Denial Reasons and Solutions
  10. FAQ

Start Here: Verify Your Plan and Find Forms

Before requesting prior authorization for Alecensa (alectinib), confirm your specific Aetna CVS Health plan details:

Step 1: Check Your Coverage

  • Log into your Aetna member portal or call the Member Services number on your ID card
  • Verify Alecensa's formulary status (typically requires PA on most plans)
  • Confirm if CVS Caremark or CVS Specialty handles your prescription benefits

Step 2: Gather Required Documents

  • ALK-positive test results (essential for approval)
  • Previous therapy history and outcomes
  • Current staging and diagnostic information
  • Prescriber's medical necessity justification
Tip: Aetna CVS Health processes most specialty medication PAs through CVS Caremark. Always verify your specific plan's pharmacy benefit manager before submitting.

Prior Authorization Forms and Requirements

Aetna CVS Health requires specific documentation for Alecensa prior authorization:

Required Forms

  • CVS Health Prior Authorization Form: Available through PrescriberPoint or the provider portal
  • Medical Necessity Letter: From your oncologist detailing clinical rationale
  • Supporting Clinical Documentation: Lab results, imaging, pathology reports

Key Requirements for Approval

Requirement Details Documentation Needed
ALK-positive status Confirmed ALK rearrangement Molecular testing report
Appropriate diagnosis Metastatic or adjuvant NSCLC Pathology report, staging
Prior therapy history Previous treatments tried/failed Treatment records, toxicity notes
Prescriber attestation Medical necessity justification Signed letter from oncologist

Submission Portals and Electronic Options

CVS Caremark Provider Portal: RxServices.CVScaremark.com

  • Faster processing (typically 24-72 hours)
  • Real-time status tracking
  • Secure document upload for supporting materials

Third-Party Platforms:

  • CoverMyMeds: Integrated with many EHR systems
  • Availity: Provider portal with Aetna integration
  • EHR Integration: Many systems connect directly to CVS Caremark

Required Provider Portal Setup

  1. Register at the CVS Caremark pharmacy portal
  2. Complete pharmacy enrollment verification
  3. Upload required credentials and contact information
  4. Access electronic prior authorization (ePA) tools
Note: Electronic submission significantly reduces processing time compared to fax or mail submissions.

Fax and Mail Submission Details

Primary Fax Number

CVS Caremark Specialty PA Fax: 1-888-267-3277

Cover Sheet Requirements

  • Patient name and date of birth
  • Aetna member ID number (numbers only, no prefixes)
  • Prescriber name and NPI
  • Medication name: Alecensa (alectinib)
  • Urgency level (standard or expedited)

Mailing Address

CVS Caremark Prior Authorization Department
(Verify current address through your provider portal or member services)

Specialty Pharmacy Setup

Alecensa is typically dispensed through CVS Specialty Pharmacy:

Enrollment Process

  1. Prescription Transfer: Your oncologist sends the prescription to CVS Specialty
  2. Benefits Verification: CVS Specialty confirms your coverage and PA status
  3. Clinical Consultation: CareTeam reviews medication, side effects, monitoring
  4. Delivery Setup: Choose home delivery or pickup options

CVS Specialty Contact

  • Member Portal: cvsspecialty.com
  • Phone: Contact number provided during enrollment
  • Services: Medication management, refill coordination, side effect monitoring

Support Lines and Contact Information

Aetna Member Services

  • Primary: Number on your Aetna ID card (personalized support)
  • General: 1-800-872-3862 (TTY: 711)
  • Hours: Monday–Friday, 8 AM–6 PM ET

Pharmacy Services

  • CVS Caremark: 1-888-792-3862 (TTY: 711)
  • Hours: Monday–Friday, 7 AM–11 PM ET; Saturday, 7 AM–9:30 PM; Sunday, 8 AM–6 PM ET

Medicare Plans (if applicable)

  • Medicare Advantage: 1-855-335-1407 (TTY: 711)
  • Prescription Drug Plans: 1-866-235-5660 (24/7)

Appeals Process: Internal and External

Internal Appeal Timeline

  • Filing Deadline: 60 calendar days from denial notice
  • Decision Timeline:
    • Standard: 30-45 business days
    • Expedited: 72 hours (with prescriber support for urgency)

Required Appeal Documentation

  • Copy of original denial letter
  • Updated medical necessity letter addressing denial reasons
  • Additional clinical evidence supporting approval
  • Prescriber statement for expedited review (if urgent)

Appeal Submission Methods

  • Online: Through Aetna member or provider portal
  • Fax: Number provided in denial letter
  • Mail: Address specified in denial correspondence

Michigan DIFS External Review

If Aetna upholds the denial after internal appeal, Michigan residents can request external review through the Department of Insurance and Financial Services (DIFS).

External Review Process

  • Eligibility: Final denial received from Aetna's internal appeal
  • Filing Deadline: 127 days from final denial notice
  • Decision Timeline:
    • Standard: Up to 60 days
    • Expedited: 72 hours (with physician letter stating urgency)

How to File

  1. Online Form: DIFS External Review Form
  2. Required Documents:
    • Copy of Aetna's final denial
    • Statement explaining your appeal
    • Supporting medical documentation
    • Treating Provider Certification (if applicable)

DIFS Contact Information

  • Phone: 877-999-6442 (Monday–Friday, 8 AM–5 PM)
  • Fax: 517-284-8838
  • Mail: DIFS Office of Appeals, P.O. Box 30220, Lansing, MI 48909-7720
Important: DIFS external review decisions are binding on your insurer. If approved, Aetna must cover the treatment.

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Missing ALK test Submit molecular testing results ALK rearrangement confirmation
Step therapy not met Request step therapy override Prior treatment failure/intolerance records
Not medically necessary Strengthen clinical justification Updated medical necessity letter, guidelines
Non-formulary status File formulary exception Prescriber statement of medical need
Quantity limits exceeded Justify dosing requirements Clinical rationale for specific dosing

Medical Necessity Letter Checklist

Your oncologist's letter should include:

  • ALK-positive NSCLC diagnosis with staging
  • Previous therapies attempted and outcomes
  • Clinical rationale for Alecensa specifically
  • Expected treatment goals and monitoring plan
  • References to NCCN guidelines or FDA labeling

FAQ

How long does Aetna CVS Health prior authorization take in Michigan? Standard PA decisions typically take 5-7 business days for electronic submissions, up to 30 days for fax/mail. Expedited requests are decided within 72 hours with prescriber support.

What if Alecensa is not on my Aetna formulary? Request a formulary exception with your prescriber's medical necessity letter. Include documentation showing why formulary alternatives are inappropriate for your specific case.

Can I request an expedited appeal if my treatment is urgent? Yes. Your oncologist must provide a letter stating that delay would seriously jeopardize your health. Both internal appeals and Michigan DIFS external reviews offer expedited options.

Does step therapy apply if I've tried other ALK inhibitors outside Michigan? Previous therapy history from any location counts toward step therapy requirements. Ensure all prior treatment records are included in your PA submission.

How much does Alecensa cost without insurance coverage? The wholesale acquisition cost is approximately $19,466 per 240-count bottle. Genentech offers patient assistance programs for eligible individuals.

What happens if DIFS denies my external review? You may seek judicial review in Michigan circuit court within 60 days of the DIFS decision, though this requires legal consultation.

Getting the right coverage for cancer treatment shouldn't add stress to an already challenging situation. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each payer's specific requirements. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization processes and appeals, reducing the administrative burden while improving approval rates.

If you're facing a denial or want to strengthen your initial submission, consider working with coverage advocates who understand both the clinical requirements for ALK inhibitors and the specific appeal processes for Counterforce Health payers like Aetna CVS Health in Michigan.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. Insurance policies and procedures may change; verify current requirements with your plan before submitting requests.

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