Answer Box: Getting Cresemba Approved by Aetna CVS Health in California

Quick Path to Approval: Aetna CVS Health requires prior authorization for Cresemba (isavuconazole) in California. Your fastest route: (1) Confirm your plan type (HMO vs PPO affects appeal rights), (2) Submit PA with diagnosis codes B44.x (aspergillosis) or B46.x (mucormycosis) plus documentation showing voriconazole failure/contraindication, (3) If denied, file internal appeal within 180 days, then request California Independent Medical Review (IMR) with ~50-60% overturn rates for drug denials.

Start today: Call the number on your insurance card and ask for "the prior authorization form for Cresemba" and confirm if CVS Specialty is your required pharmacy.

Table of Contents

1. What This Guide Covers
2. Before You Start: Plan Verification
3. Gather Required Documentation
4. Submit Your PA Request
5. Follow-Up and Tracking
6. Typical Timelines in California
7. If You Need More Information
8. If Your Request is Denied
9. California Independent Medical Review
10. Renewal and Re-authorization
11. Frequently Asked Questions
12. Quick Reference Checklist

What This Guide Covers

This comprehensive guide helps California patients and their healthcare teams navigate Aetna CVS Health's prior authorization process for Cresemba (isavuconazole). Whether you're dealing with invasive aspergillosis or mucormycosis, this step-by-step approach can significantly improve your approval odds.

Cresemba is a high-cost antifungal medication (around $1,620 for a 14-day supply) used to treat serious invasive fungal infections. Most insurance plans, including Aetna CVS Health, require prior authorization due to the medication's cost and the need to ensure appropriate use for FDA-approved indications.

Who this helps: Patients with Aetna CVS Health coverage in California, their caregivers, and healthcare providers managing invasive aspergillosis or mucormycosis cases.

Before You Start: Plan Verification

Determine Your Plan Type

Your appeal rights depend on whether you have an HMO regulated by California's Department of Managed Health Care (DMHC) or a different plan type:

• DMHC-regulated plans: Access to California's Independent Medical Review (IMR) with binding decisions
• ERISA/self-funded plans: Federal external review process applies
• Aetna Better Health (Medicaid): State fair hearing rights available

Check your insurance card for "Aetna Health of California, Inc." or DMHC language, or call the member services number to confirm.

Verify Pharmacy Network

Most Aetna CVS Health plans route specialty medications like Cresemba through CVS Specialty Pharmacy. Confirm this requirement early, as using an out-of-network pharmacy can complicate coverage.

Coverage at a Glance

Requirement	What It Means	Where to Find It
Prior Authorization	Required before dispensing	PA form via provider portal or member services
Formulary Status	Typically Tier 3-4 specialty	Plan formulary document
Specialty Pharmacy	Usually CVS Specialty required	Insurance card or member handbook
Age Restrictions	Adults and pediatric ≥6 years/≥16 kg (capsules)	FDA labeling
Diagnosis Codes	B44.x (aspergillosis), B46.x (mucormycosis)	ICD-10 coding guidelines

Gather Required Documentation

Before submitting your PA request, compile these essential documents:

Clinical Documentation Checklist

• Insurance information: Front and back of insurance card, member ID
• Diagnosis confirmation: ICD-10 codes B44.0-B44.9 for invasive aspergillosis or B46.0-B46.9 for mucormycosis
• Microbiologic evidence: Culture results, PCR, galactomannan, or histopathology reports
• Imaging reports: CT chest/sinuses, MRI showing invasive disease
• Prior treatment history: Documentation of voriconazole failure, intolerance, or contraindications
• Specialist consultation: Infectious disease or hematology/oncology notes
• Current medications: Complete list to identify drug interactions

Medical Necessity Letter Components

Your infectious disease specialist should include:

• Confirmed diagnosis of invasive aspergillosis or mucormycosis
• Why voriconazole is inappropriate (QT prolongation risk, drug interactions, hepatotoxicity, documented failure)
• Expected treatment duration and monitoring plan
• Risk of treatment delay or alternative therapy failure

Tip: Counterforce Health specializes in turning insurance denials into successful appeals by analyzing payer policies and crafting evidence-backed responses. Their platform can help identify the specific documentation Aetna CVS Health requires and streamline your appeal process.

Submit Your PA Request

Step-by-Step Submission Process

1. Obtain the correct form: Call Aetna member services or access the provider portal for the current Cresemba PA form
2. Complete all sections: Include ICD-10 codes, prior therapies, and clinical rationale
3. Submit via preferred method:
   • Electronic PA (ePA) through provider portal (fastest)
   • Fax to CVS Caremark Prior Authorization Department
   • Phone submission for urgent cases

Required Information for Aetna CVS Health

Based on typical antifungal PA policies, expect these requirements:

• Age verification: Within FDA-approved range
• Appropriate indication: Invasive aspergillosis or mucormycosis only
• Specialist involvement: ID consultation documented
• Alternative therapy rationale: Why voriconazole cannot be used
• Dosing plan: Standard loading and maintenance doses

Manufacturer Support

CRESEMBA Support Solutions offers free assistance:

• Benefits verification and PA form completion
• Direct submission to insurers (with provider authorization)
• Status tracking and results communication
• Available at astellaspharmasupportsolutions.com

Follow-Up and Tracking

When to Call

• Day 3-5: Confirm PA receipt and completeness
• Day 10-12: Check decision status for standard requests
• Day 15+: Escalate if no decision received

Sample Call Script

"Hi, I'm calling to check the status of a prior authorization for Cresemba submitted on [date] for member [name], ID [number]. Can you tell me if additional information is needed or when I can expect a decision?"

Document all interactions with reference numbers, representative names, and next steps.

Typical Timelines in California

Standard Processing

• CVS Caremark PA decisions: 5-15 business days after complete submission
• Expedited/urgent requests: 36-72 hours when medical urgency documented
• Appeals (internal): 30-45 days for standard, 72 hours for expedited

California-Specific Protections

California's utilization review regulations require:

• Timely processing of PA requests
• Clear denial reasons with specific policy citations
• Right to expedited review for urgent medical situations

If You Need More Information

Common Additional Requests

If Aetna requests more information, they typically need:

• Updated imaging: Recent CT or MRI showing disease progression
• Laboratory results: Fungal biomarkers, liver function tests
• Treatment response: Documentation of clinical improvement or failure on current therapy
• Drug interaction assessment: Detailed medication reconciliation

Strengthening Your Case

• Cite major infectious disease guidelines supporting Cresemba use
• Include peer-reviewed literature for your specific indication
• Document any emergency department visits or hospitalizations related to fungal infection
• Provide specialist attestation of medical necessity

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason	How to Address
"Not medically necessary"	Submit detailed specialist letter with clinical evidence
"Step therapy not met"	Document voriconazole contraindications or failures
"Non-formulary"	Request formulary exception with medical necessity
"Experimental/investigational"	Cite FDA approval and clinical guidelines

Internal Appeal Process

You have 180 calendar days from the denial date to file an internal appeal with Aetna CVS Health:

1. Request expedited review if medically urgent
2. Submit additional clinical evidence addressing denial reasons
3. Request peer-to-peer review between your specialist and Aetna's medical director
4. Track all deadlines and maintain documentation

California Independent Medical Review

When IMR Applies

For DMHC-regulated Aetna plans, you can request Independent Medical Review after internal appeal denial for:

• Medical necessity disputes
• Experimental/investigational denials
• Emergency or urgent care disputes

IMR Success Rates

California's IMR process shows approximately 50-60% overturn rates for drug denials overall. Success factors include:

• Strong specialist support
• Clear documentation of alternative therapy failures
• Evidence-based medical necessity arguments
• Timely submission with complete records

How to File IMR

1. Complete Aetna's internal appeal first (unless urgent)
2. Contact DMHC Help Center: 888-466-2219
3. Submit IMR application with all clinical documentation
4. Independent physician review: Binding decision within 30-45 days

Note: There's no fee for California IMR, and the decision is binding on your insurance plan.

Renewal and Re-authorization

Planning Ahead

Cresemba approvals typically last 3 months initially. Calendar your renewal request 2-3 weeks before expiration.

Renewal Documentation

Include:

• Clinical response: Imaging improvements, symptom resolution
• Ongoing medical necessity: Risk factors, immunosuppression status
• Tolerance assessment: Lack of significant side effects
• Treatment plan: Expected duration and monitoring

Frequently Asked Questions

Q: How long does Aetna CVS Health PA take in California? A: Standard requests typically take 5-15 business days. Expedited requests for urgent medical situations are processed within 36-72 hours.

Q: What if Cresemba is non-formulary on my plan? A: You can request a formulary exception by demonstrating medical necessity and documenting why formulary alternatives are inappropriate.

Q: Can I appeal if I'm on a self-funded employer plan? A: Yes, but you'll use federal external review rather than California's IMR process. Your plan documents will specify the procedure.

Q: Does step therapy apply if I failed voriconazole outside California? A: Yes, documented treatment failures from any location are typically accepted if properly documented.

Q: What happens if CVS Specialty isn't in my area? A: CVS Specialty provides nationwide mail-order service. Contact them directly to arrange delivery to California.

Q: Can I get financial assistance for Cresemba? A: Yes, check manufacturer copay programs and patient assistance foundations. Astellas offers support through CRESEMBA Support Solutions.

Quick Reference Checklist

Before Submitting PA:

• Confirm Aetna plan type and appeal rights
• Verify CVS Specialty requirement
• Collect diagnosis codes (B44.x or B46.x)
• Document voriconazole contraindications
• Obtain infectious disease consultation
• Gather microbiology and imaging reports

During PA Process:

• Submit via electronic portal when possible
• Request expedited review if urgent
• Track submission with reference numbers
• Follow up within 5 business days
• Prepare appeal materials proactively

If Denied:

• File internal appeal within 180 days
• Request peer-to-peer review
• Gather additional clinical evidence
• Consider California IMR for DMHC plans
• Document all interactions and deadlines

---

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals through targeted, evidence-backed strategies. By analyzing payer policies and crafting point-by-point rebuttals, their platform significantly improves approval rates for complex medications like Cresemba. Learn more at counterforcehealth.org.

Sources & Further Reading

• Aetna Member Rights and Resources - Appeals
• CVS Caremark Prior Authorization Information
• CRESEMBA Support Solutions
• California DMHC Help Center
• FDA Cresemba Prescribing Information

---

Disclaimer: This guide provides general information about insurance processes and should not be considered medical or legal advice. Always consult with your healthcare provider about treatment decisions and verify current policies with your insurance plan. Coverage policies and procedures may change without notice.

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