By Counterforce Health Team in Dupixent (dupilumab) —

How to Get Dupixent (dupilumab) Covered by Aetna (CVS Health) in California: Complete Prior Authorization Guide

Answer Box: Get Dupixent Covered by Aetna in California

Fastest Path to Approval: Aetna requires prior authorization for all Dupixent uses. Your dermatologist or allergist must submit documentation showing failed trials of topical treatments (corticosteroids and calcineurin inhibitors) within 180 days, plus proof of moderate-to-severe disease. Standard approval takes 30-45 days; expedited requests process within 72 hours for urgent cases. If denied, California residents can file an Independent Medical Review (IMR) through the DMHC—though success rates are modest at 10-13% for specialty drugs.

First Step Today: Contact your prescribing specialist to gather treatment history and initiate the PA request through Aetna's provider portal.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding and Documentation
  5. Required Documentation Packet
  6. Submission Process
  7. CVS Specialty Pharmacy Setup
  8. After Submission: What to Expect
  9. Appeals Process in California
  10. Common Denial Reasons & How to Fix Them
  11. Costs and Patient Support
  12. Quick Reference Checklist

Who Should Use This Guide

This comprehensive guide is designed for California patients with Aetna (CVS Health) coverage who need Dupixent for FDA-approved conditions: moderate-to-severe atopic dermatitis, asthma, chronic rhinosinusitis with nasal polyps, prurigo nodularis, eosinophilic esophagitis, or COPD with eosinophilic phenotype.

Expected Outcome: With proper documentation, most medically appropriate Dupixent requests receive approval. However, initial denials are common—approximately 22% of Aetna requests face denial, often due to incomplete step therapy documentation or missing clinical details.

Member & Plan Basics

Coverage Requirements

  • Active Aetna Coverage: Verify your plan includes specialty pharmacy benefits through CVS Caremark
  • Plan Types: All Aetna commercial plans, Medicare Advantage, and Medicaid managed care require prior authorization
  • Deductible Impact: Dupixent typically applies toward medical (not pharmacy) deductible as a specialty biologic
  • Authorization Validity: Initial approvals typically last 4 months; renewals extend to 12 months with documented clinical benefit
Tip: Call the member services number on your insurance card to confirm your specialty pharmacy benefits and any applicable copay amounts before starting the PA process.

Clinical Criteria Requirements

Prescriber Requirements

Dupixent must be prescribed by or in consultation with:

  • Dermatologist (for atopic dermatitis, prurigo nodularis)
  • Allergist/Immunologist (for asthma, atopic dermatitis)
  • Pulmonologist (for asthma, COPD)
  • ENT specialist (for chronic rhinosinusitis with nasal polyps)

Condition-Specific Criteria

Atopic Dermatitis (Age ≥6 months):

  • Moderate-to-severe disease (≥10% body surface area or involvement of hands, feet, face, neck, genitals)
  • Failed trials of both high-potency topical corticosteroids AND topical calcineurin inhibitors within past 180 days
  • Documentation of inadequate response, intolerance, or contraindication to required therapies

Asthma (Age ≥6 years):

  • Moderate-to-severe persistent asthma despite inhaled corticosteroids and controller medications
  • Eosinophilic phenotype preferred (blood eosinophils ≥150 cells/μL or fractional exhaled nitric oxide ≥25 ppb)
  • Documentation of exacerbations or oral corticosteroid dependence

Coding and Documentation

ICD-10 Diagnosis Codes

Condition Primary Codes Notes
Atopic Dermatitis L20.0, L20.81, L20.82, L20.84, L20.89, L20.9 Document severity and location
Asthma J45.4, J45.5, J82.83 (eosinophilic) Include phenotype documentation
CRSwNP J33.1, J33.8, J33.9 Age ≥18 years required
Prurigo Nodularis L28.1 Age ≥18 years required
Eosinophilic Esophagitis K20.0 Age ≥1 year, weight ≥15kg
COPD (Eosinophilic) J44.0, J44.1, J44.9 Must document eosinophilic phenotype

HCPCS/NDC Codes

  • HCPCS: J3590 (unclassified biologics) or specific Dupixent code if available
  • NDC: 0024-5910-02 (300mg/2mL prefilled pen, 2-pack)

Required Documentation Packet

Medical Necessity Letter Components

Your specialist must include:

  1. Patient demographics and insurance information
  2. Specific diagnosis with ICD-10 code and disease severity assessment
  3. Treatment history with exact medications, dosages, duration, and outcomes
  4. Clinical rationale for Dupixent vs. alternatives
  5. Treatment goals and monitoring plan
  6. Prescriber credentials and specialty board certification

Supporting Attachments

  • Recent office visit notes (within 90 days)
  • Laboratory results (eosinophil counts, total IgE if relevant)
  • Clinical photographs for dermatologic conditions
  • Prior authorization history or denial letters
  • Pharmacy records showing previous treatment failures
From our advocates: We've seen the strongest approvals when providers include specific dates, dosages, and documented side effects for each failed therapy. Generic statements like "patient failed topical treatments" often lead to requests for more information, delaying approval by weeks.

Submission Process

Aetna Prior Authorization Submission

  1. Access the portal: Use Aetna's provider portal or CVS Caremark system
  2. Complete PA form: Use the most current California-specific form
  3. Attach documentation: Upload all required clinical records
  4. Submit expedited request if medically urgent (requires clinical justification)
  5. Track submission: Record confirmation number and expected decision date

Timeline Expectations:

  • Standard decisions: 30-45 days
  • Expedited decisions: Within 72 hours
  • Additional information requests: 14-day response window

CVS Specialty Pharmacy Setup

Since Aetna typically requires specialty medications through CVS Specialty, coordinate the pharmacy setup:

Enrollment Process

  1. Provider referral: Prescriber sends prescription via ePrescribe (code 1466033) or fax to CVS Specialty
  2. Patient enrollment: CVS Specialty contacts patient for insurance verification and delivery preferences
  3. Delivery coordination: Choose home, work, doctor's office, or CVS Pharmacy pickup

Transfer from Another Specialty Pharmacy

  • Contact CVS Specialty directly with current prescription information
  • Provide insurance details and prescriber contact
  • Allow 3-5 business days for transfer completion

After Submission: What to Expect

Tracking Your Request

  • Confirmation number: Save this for all follow-up calls
  • Status checks: Call Aetna member services weekly for updates
  • Additional information requests: Respond within 14 days to avoid delays

What to Record

  • Submission date and confirmation number
  • Expected decision date
  • Any requests for additional information
  • Names and reference numbers from phone conversations

Appeals Process in California

If your initial request is denied, California offers robust appeal rights through two regulatory bodies.

Internal Appeal with Aetna

  • Timeline: File within 180 days of denial notice
  • Process: Submit appeal letter with additional clinical documentation
  • Decision: 30 days for standard appeals, 72 hours for expedited

California Independent Medical Review (IMR)

For DMHC-regulated plans (most HMOs and managed care):

  • File IMR application within 30 days of final internal denial
  • Contact DMHC Help Center: (888) 466-2219
  • Online application: healthhelp.ca.gov
  • Decision timeline: 45 days standard, 7 days expedited
  • No cost to patient

Success rates: Approximately 10-13% of specialty drug appeals are overturned through IMR, making strong initial documentation crucial.

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to identify specific denial reasons, then drafts point-by-point rebuttals using FDA labeling, peer-reviewed studies, and specialty guidelines aligned to each payer's requirements.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Insufficient step therapy Provide detailed prior treatment records Specific medications, dates, dosages, outcomes
Non-formulary status Request formulary exception Medical necessity letter, alternative failures
Lack of specialist Confirm prescriber credentials Board certification, specialty attestation
Missing severity documentation Submit clinical assessments Photos, validated severity scales, BSA measurements
Experimental/investigational Cite FDA approval and guidelines FDA labeling, specialty society recommendations

Costs and Patient Support

Financial Assistance Options

  • Dupixent MyWay: Manufacturer copay assistance program (verify eligibility)
  • Sanofi Patient Connection: Need-based assistance program
  • California state programs: Medi-Cal coverage for eligible patients
  • Foundation grants: Organizations like PAN Foundation or HealthWell Foundation

Cost Transparency

  • List price: Approximately $3,993 per carton (2 injections) as of January 2025
  • Most patients pay significantly less with insurance and assistance programs
  • Annual costs can exceed $100,000 without coverage

Quick Reference Checklist

Before Starting:

  • Verify active Aetna coverage with specialty pharmacy benefits
  • Confirm prescriber is appropriate specialist
  • Gather complete treatment history with dates and outcomes
  • Document current disease severity

For Submission:

  • Complete most current CA-specific PA form
  • Include medical necessity letter with all required elements
  • Attach supporting clinical documentation
  • Submit through correct portal with tracking number
  • Set calendar reminders for follow-up

If Denied:

  • File internal appeal within 180 days
  • Consider Counterforce Health for appeal assistance
  • Prepare IMR application if internal appeal fails
  • Contact DMHC Help Center for guidance

Frequently Asked Questions

How long does Aetna prior authorization take in California? Standard decisions take 30-45 days. Expedited requests for urgent medical needs are processed within 72 hours.

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

Can I request an expedited appeal? Yes, if you can demonstrate urgent medical need. Expedited appeals are decided within 72 hours.

Does step therapy apply if I failed treatments outside California? Yes, treatment failures from any location count toward step therapy requirements if properly documented.

What happens if my IMR is denied? IMR decisions are binding on your health plan. Further options are limited, though you may consult with a healthcare attorney for complex cases.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage policies change frequently, and individual circumstances vary. Always verify current requirements with your insurance plan and healthcare providers. For personalized assistance with complex appeals, consider consulting with healthcare coverage specialists or legal professionals familiar with California insurance law.

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