By Counterforce Health Team in Chenodal (chenodiol) —

How to Get Chenodal (chenodiol) Covered by Aetna (CVS Health) in Virginia: Prior Authorization Guide and Appeals Process

Answer Box: Getting Chenodal (chenodiol) Covered by Aetna (CVS Health) in Virginia

Fastest Path: Aetna (CVS Health) typically requires prior authorization for Chenodal (chenodiol) and often mandates trying ursodiol first (step therapy). To get approval in Virginia: (1) Have your doctor submit a prior authorization request with imaging confirming radiolucent gallstones and documentation that you're not a surgical candidate, (2) If denied, file an internal appeal within 180 days with evidence of ursodiol failure or contraindications, (3) After final internal denial, request external review through Virginia's State Corporation Commission Bureau of Insurance within 120 days. Standard decisions take 30-45 days; expedited appeals are decided within 72 hours if health is at risk.

Start Today: Call the number on your Aetna (CVS Health) member ID card to check Chenodal's formulary status and prior authorization requirements for your specific plan.

Table of Contents

  1. When Alternatives Make Sense
  2. Typical Formulary Alternatives
  3. Prior Authorization Strategy
  4. Appeals Process in Virginia
  5. Step Therapy Override Requirements
  6. Switching Logistics and Monitoring
  7. Re-trying for Chenodal Later
  8. FAQ

When Alternatives Make Sense

Before pursuing Chenodal (chenodiol) coverage, it's important to understand that Aetna (CVS Health) typically prefers ursodiol as first-line therapy for gallstone dissolution. According to clinical evidence, ursodiol is generally preferred over chenodiol due to superior tolerability and comparable efficacy, with complete dissolution rates of 14-52% at 6-12 months for stones ≤5 mm.

Chenodal may be considered when:

  • Ursodiol has failed after an adequate trial (typically 6-12 months)
  • Patient cannot tolerate ursodiol due to side effects
  • Specific contraindications to ursodiol exist
  • Patient has radiolucent cholesterol gallstones and is not a surgical candidate
Note: Switching from ursodiol to chenodiol requires careful monitoring due to chenodiol's hepatotoxicity risk and should only be done under specialist supervision.

Typical Formulary Alternatives

Aetna CVS Health plans generally prefer ursodiol for gallstone dissolution and often require prior authorization and/or step therapy before covering chenodiol.

Coverage at a Glance

Medication Typical Formulary Status PA Required Step Therapy Monitoring
Ursodiol (generic) Preferred Usually No No Periodic imaging
Chenodal (chenodiol) Non-preferred/PA Yes Yes (try ursodiol first) Monthly LFTs initially

Ursodiol: The Preferred Alternative

Pros:

  • Better tolerated than chenodiol
  • Lower hepatotoxicity risk
  • Usually covered without prior authorization
  • Generic versions available at lower cost

Cons:

  • May take 6-24 months for dissolution
  • Not effective for calcified or pigment stones
  • High recurrence rates after successful dissolution

Typical Coverage Requirements:

  • Diagnosis of radiolucent cholesterol gallstones
  • Functioning gallbladder confirmed by imaging
  • Patient not a surgical candidate or refuses surgery

Prior Authorization Strategy

Required Documentation

When requesting Chenodal coverage, your doctor should include:

Clinical Evidence:

  • Recent imaging (ultrasound or CT) confirming radiolucent cholesterol gallstones
  • Gallbladder function studies showing patent, functioning gallbladder
  • Documentation that patient is poor surgical candidate or refuses surgery
  • Baseline liver function tests (ALT, AST, bilirubin)

Step Therapy Documentation (if ursodiol tried first):

  • Pharmacy records showing ursodiol trial duration and dosing
  • Clinical notes documenting inadequate response or intolerance
  • Specific adverse effects or contraindications to ursodiol

Medical Necessity Letter Checklist:

  • Patient's diagnosis with ICD-10 codes
  • Size and characteristics of gallstones from imaging
  • Surgical risk assessment or patient refusal documentation
  • Treatment goals and expected duration
  • Monitoring plan for hepatotoxicity

Submission Process

Aetna allows step therapy overrides via medical exceptions when prescribers submit documentation proving medical necessity.

How to Submit:

  1. Call the number on your member ID card for expedited review
  2. Use Aetna's online provider portal
  3. Fax completed forms (verify current fax number with Aetna)

Expected Timeline:

  • Standard decisions: 30-45 business days
  • Expedited review: 72 hours if health is at risk
  • Medicare Part B/Advantage: 72 hours standard, 24 hours expedited

Appeals Process in Virginia

Internal Appeals with Aetna (CVS Health)

If your initial prior authorization is denied, you have 180 days to file an internal appeal with Aetna.

Appeal Requirements:

  • Submit new clinical evidence not included in original request
  • Pharmacy records showing step therapy compliance
  • Updated labs or imaging if available
  • Physician attestation of medical necessity

Timeline:

  • Standard internal appeal decision: 45 business days
  • Expedited appeal: 36-72 hours with physician certification of urgency

Virginia External Review Process

After completing Aetna's internal appeals, Virginia residents can request external review through the State Corporation Commission Bureau of Insurance.

Key Details:

  • File within 120 days of final internal denial
  • Standard external review: decided within 45 days
  • Expedited external review: 72 hours for urgent cases
  • No fee for external review
  • Decision is binding on Aetna

Required Documents:

  • Final denial notice from Aetna
  • All internal appeal documentation
  • Medical records supporting medical necessity
  • Completed Form 216-A (External Review Request)

Contact Information:

  • Virginia SCC Bureau of Insurance: (804) 371-9691
  • Consumer Services: 1-877-310-6560
From Our Advocates: "We've seen several Virginia patients successfully overturn Chenodal denials by documenting specific ursodiol side effects like persistent nausea or lack of stone size reduction after 8-12 months. The key is having your gastroenterologist provide detailed clinical notes about why chenodiol is medically necessary for your specific case."

Step Therapy Override Requirements

Aetna's step therapy policies require trying preferred alternatives before covering non-preferred drugs like Chenodal.

Documentation for Override

Ursodiol Trial Requirements:

  • Minimum 6-month trial at appropriate dose (7-15 mg/kg/day)
  • Documentation of inadequate response (no stone size reduction)
  • Specific intolerability (GI upset, fatigue, etc.)
  • Contraindications to continued ursodiol therapy

Acceptable Failure Criteria:

  • No improvement in stone size after 6-12 months
  • Worsening symptoms despite compliance
  • Development of adverse effects requiring discontinuation
  • Patient-specific factors making ursodiol inappropriate

Switching Logistics and Monitoring

Provider Coordination

Lead Prescriber: A gastroenterologist or hepatologist should manage the transition due to chenodiol's hepatotoxicity risk.

Required Baseline Testing:

  • Comprehensive liver panel (AST, ALT, ALP, GGT, bilirubin)
  • Complete blood count
  • Pregnancy test for women of childbearing age
  • Fasting lipid profile

Monitoring Schedule

First 3 Months:

  • Liver function tests every 2 weeks during dose titration
  • Monthly LFTs once at target dose

Months 4-12:

  • LFTs every 1-3 months if stable

Ongoing:

  • LFTs every 3 months throughout therapy
  • Ultrasound at 6-12 months to assess dissolution
  • Immediate discontinuation if ALT/AST >3× ULN with symptoms

Pharmacy Considerations

Contraindication Screening:

  • Baseline liver disease
  • Pregnancy or breastfeeding
  • Radio-opaque or pigment gallstones

Drug Interactions:

  • Separate from bile acid sequestrants by several hours
  • Avoid aluminum-containing antacids

Re-trying for Chenodal Later

If your initial request is denied, document the following during any ursodiol trial:

Clinical Response Tracking:

  • Serial imaging showing stone size changes
  • Symptom diary documenting biliary pain episodes
  • Any adverse effects or intolerability
  • Compliance with therapy and monitoring

When to Resubmit:

  • After 6-month ursodiol trial showing inadequate response
  • If new contraindications to ursodiol develop
  • With additional specialist consultation supporting chenodiol use

Strengthening Your Case:

  • Obtain second opinion from hepatology/gastroenterology
  • Document quality of life impact from continued symptoms
  • Include peer-reviewed literature supporting chenodiol use in your specific case

At Counterforce Health, we help patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to identify the specific denial basis and draft point-by-point rebuttals aligned to the plan's own rules, incorporating the right clinical evidence and citations to maximize approval chances.

FAQ

How long does Aetna (CVS Health) prior authorization take in Virginia? Standard PA decisions take 30-45 business days. Expedited reviews are completed within 72 hours if your doctor certifies that waiting could jeopardize your health.

What if Chenodal is non-formulary on my plan? You can request a formulary exception by documenting that all formulary alternatives (like ursodiol) are inappropriate due to failure, contraindications, or intolerance.

Can I request an expedited appeal in Virginia? Yes, if your physician certifies that waiting for a standard appeal could seriously jeopardize your health or ability to regain function. Expedited appeals are decided within 36-72 hours.

Does step therapy apply if I tried ursodiol outside Virginia? Yes, pharmacy records and clinical notes from any state showing adequate ursodiol trial and failure should satisfy Aetna's step therapy requirements.

What happens if external review overturns the denial? Aetna must provide coverage within 1-3 days of a favorable external review decision. For expedited cases, authorization must occur within 24 hours.

Are there cost assistance programs for Chenodal? Contact Travere Therapeutics (the manufacturer) directly to inquire about patient assistance programs. Some patients may qualify for copay reduction or free drug programs based on income.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and is not medical advice. Always consult with your healthcare provider about your specific medical condition and treatment options. Insurance coverage decisions are made by individual plans and may vary. For personalized assistance with your appeal, contact Virginia's Consumer Services at 1-877-310-6560 or visit life.virginia.gov for official external review information.

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