By Counterforce Health Team in Dupixent (dupilumab) —

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

Answer Box: Getting Dupixent Covered by Aetna in Georgia

Aetna requires prior authorization for Dupixent (dupilumab) with documented step therapy failures. Your fastest path: 1) Gather records of failed topical treatments, 2) Have your dermatologist/allergist submit Aetna's specialty PA form with clinical notes, 3) If denied, appeal within 65 days and request Georgia external review if needed. Most approvals take 7-15 days with complete documentation. Start by downloading Aetna's current PA form and scheduling with a specialist.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Documentation Packet
  5. Submission Process
  6. CVS Specialty Pharmacy Setup
  7. After Submission: What to Expect
  8. Appeals Process in Georgia
  9. Common Denial Reasons & Fixes
  10. Cost-Saving Options
  11. Quick Reference Checklist

Who Should Use This Guide

This guide is for Georgia residents with Aetna coverage who need Dupixent (dupilumab) for moderate-to-severe atopic dermatitis, asthma, chronic rhinosinusitis with nasal polyps, or other FDA-approved conditions. You'll also find this useful if you've already been denied and need to appeal.

Expected outcome: With proper documentation, most Dupixent requests are approved. If initially denied, Georgia's external review process has helped many patients overturn wrongful denials when medical necessity is clearly documented.

Member & Plan Basics

Coverage Requirements

Active Coverage: Verify your Aetna plan is active and includes prescription benefits. Dupixent is typically covered under the medical benefit (not pharmacy) for some plans.

Plan Types: Requirements are similar across Aetna commercial, Medicare Advantage, and Medicaid plans, though specific forms may vary.

Prior Authorization: Always required for Dupixent across all Aetna plans. No exceptions for step therapy requirements.

Coverage at a Glance

Requirement Details Source
Prior Authorization Required for all indications Aetna PA List
Formulary Status Covered with PA Aetna Drug Guide
Step Therapy Required (see criteria below) Aetna Policy
Quantity Limits Standard FDA dosing Aetna Limits
Prescriber Requirements Dermatologist or allergist/immunologist Clinical Policy

Clinical Criteria Requirements

For Atopic Dermatitis (Most Common)

Diagnosis Requirements:

  • Moderate-to-severe atopic dermatitis
  • ≥10% body surface area involvement
  • Appropriate ICD-10 codes: L20.0, L20.81-L20.84, L20.89, L20.9

Step Therapy Requirements: You must have tried and failed (or have contraindications to):

  • High or super-high potency topical corticosteroid OR
  • Topical calcineurin inhibitor (tacrolimus, pimecrolimus)

Alternative pathway: Prior use of another biologic (Adbry) or targeted synthetic (Cibinqo, Rinvoq) in past 180 days also meets criteria.

For Asthma

Requirements:

  • Moderate-to-severe asthma as add-on therapy
  • Eosinophilic phenotype OR oral corticosteroid dependence
  • Pre-treatment eosinophil count documentation
  • ICD-10 codes: J45.40-J45.998

For Chronic Rhinosinusitis with Nasal Polyps

Requirements:

  • Documented nasal polyps via endoscopy
  • Prior treatment failures documented
  • ICD-10 codes: J32.9, J33.0-J33.9

Documentation Packet

Required Documents

1. Prior Authorization Form

  • Use Aetna's current specialty medication PA form
  • Must be completed by prescribing physician
  • Download from Aetna provider portal

2. Letter of Medical Necessity Your physician should include:

  • Patient identification (name, DOB, member ID)
  • Specific ICD-10 diagnostic codes
  • Date of initial diagnosis
  • Body surface area involvement (for atopic dermatitis)
  • Detailed symptom description
  • Complete prior treatment history with dates, doses, duration, and outcomes
  • Clinical justification for Dupixent
  • Treatment goals and monitoring plan

3. Clinical Documentation

  • Current chart notes documenting diagnosis and severity
  • Photos of affected areas (for dermatologic conditions)
  • Recent lab results (eosinophil counts for asthma)
  • Endoscopy reports (for nasal polyps)

4. Prior Treatment Records Document each failed therapy with:

  • Medication name and strength
  • Start and stop dates
  • Duration of trial
  • Reason for discontinuation (lack of efficacy, side effects)
  • Clinical response or lack thereof
Tip: Organize documents chronologically. Aetna reviewers appreciate clear timelines showing treatment progression.

Submission Process

Step-by-Step Submission

1. Prescriber Preparation (1-2 days)

  • Gather all clinical documentation
  • Complete PA form and letter of medical necessity
  • Ensure specialist credentials match Aetna requirements

2. Submit to Aetna (Day 1)

  • Online: Aetna provider portal (preferred method)
  • Fax: Check current fax number on PA form
  • Phone: 1-866-235-5660 for urgent cases
  • Keep confirmation numbers

3. Confirmation (Within 24 hours)

  • Verify receipt via portal or phone
  • Note case/reference number
  • Confirm all documents were received

4. Follow-up (Days 5-7)

  • Check status online or call member services
  • Respond promptly to any requests for additional information

Required Coding

HCPCS Code: J3590 (Unclassified biologics) - specify dupilumab (Dupixent)

ICD-10 Codes by Condition:

  • Atopic dermatitis: L20.0, L20.81-L20.84, L20.89, L20.9
  • Asthma: J45.40-J45.998
  • Chronic rhinosinusitis: J32.9, J33.0-J33.9

CVS Specialty Pharmacy Setup

Aetna members typically must use CVS Specialty for Dupixent to receive full insurance benefits.

Transfer Process

1. Prescriber Action

  • Submit prescription and enrollment form to CVS Specialty
  • Phone: 1-800-237-2767
  • Fax: 1-800-323-2445
  • Download enrollment forms at CVS Specialty enrollment

2. CVS Specialty Processing

  • Benefits verification
  • Prior authorization coordination
  • Patient outreach for delivery preferences

3. Patient Setup

  • CVS CareTeam will contact you
  • Schedule delivery (home, work, or CVS store)
  • Arrange injection training if needed
  • Set up financial assistance if applicable

After Submission: What to Expect

Timeline

  • Standard Review: 7-15 business days
  • Expedited Review: 72 hours (if urgent medical need)
  • Additional Information Requests: May extend timeline by 5-10 days

Tracking Your Request

What to Monitor:

  • Confirmation of receipt
  • Requests for additional information
  • Approval or denial notification
  • Prior authorization number (if approved)

Status Check Methods:

  • Aetna member portal
  • Phone: 1-866-235-5660
  • Provider portal (for your doctor's office)

Appeals Process in Georgia

If your initial request is denied, Georgia law provides robust appeal rights.

Internal Appeals with Aetna

Level 1: Standard Appeal

  • Deadline: 65 days from denial letter
  • Timeline: 7 days for decision (72 hours if expedited)
  • Submit: Online portal, mail, or fax per denial instructions

Level 2: Second Internal Appeal

  • Available if first appeal is denied
  • Same timeline and submission methods

Georgia External Review

After exhausting Aetna's internal appeals, you can request an independent external review through Georgia's Department of Insurance.

Key Details:

  • Deadline: 60 days from final internal denial
  • Cost: Free to consumers
  • Timeline: 15 days for standard review, 72 hours for expedited
  • Decision: Binding on Aetna
  • Contact: Georgia DOI Consumer Services: 1-800-656-2298
Note: Georgia allows concurrent external review with expedited internal appeals if delay could seriously jeopardize your health.

Appeal Documentation

Include with your appeal:

  • Copy of denial letter
  • Updated letter of medical necessity
  • Any new clinical information
  • Peer-reviewed literature supporting Dupixent use
  • Patient impact statement

Common Denial Reasons & Fixes

Denial Reason How to Fix Required Documentation
Inadequate step therapy Document specific failures Detailed treatment history with dates, doses, outcomes
Missing specialist Get referral to dermatologist/allergist Specialist consultation notes
Insufficient severity Better document disease impact Photos, quality of life assessments, BSA measurements
Lack of medical necessity Strengthen clinical justification Updated letter with guideline citations
Missing lab values Submit required tests Eosinophil counts, allergy testing results

From Our Advocates

In our experience helping patients navigate specialty drug approvals, the most successful appeals combine comprehensive medical documentation with clear explanations of how previous treatments failed to control symptoms. One pattern we've observed is that appeals including both clinical photos and patient impact statements tend to have higher approval rates, particularly when the treating physician clearly explains why Dupixent specifically is the most appropriate next step.

Cost-Saving Options

Even with insurance approval, Dupixent can be expensive. Here are assistance options:

Manufacturer Support

  • DUPIXENT MyWay®: 1-844-387-4936
  • Copay assistance for eligible patients
  • Patient support services
  • Appeals assistance

Additional Resources

  • Patient Advocate Foundation: Copay relief program
  • Good Days: Chronic disease fund
  • Georgia pharmacy assistance programs: Check with Georgia Department of Community Health

Quick Reference Checklist

Before You Start

  • Active Aetna coverage verified
  • Specialist appointment scheduled (dermatologist/allergist)
  • Prior treatment records gathered
  • Photos of affected areas taken
  • Lab results obtained (if applicable)

Documentation Packet

  • Completed PA form
  • Letter of medical necessity
  • Clinical notes with diagnosis and severity
  • Prior treatment failure documentation
  • Recent lab results/imaging
  • ICD-10 codes verified

After Submission

  • Confirmation number recorded
  • Follow-up scheduled for day 7
  • CVS Specialty enrollment initiated
  • Appeal deadline noted (65 days)

Need help navigating insurance approvals? Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, identifying specific coverage criteria, and crafting evidence-backed responses that speak directly to payer policies. Their platform helps patients, clinicians, and specialty pharmacies get prescription drugs approved faster with targeted, professional appeals.

For complex cases or repeated denials, consider working with coverage advocates who understand Aetna's specific requirements and can help present your case in the strongest possible way. Counterforce Health offers tools and expertise specifically designed to improve approval rates for specialty medications like Dupixent.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage processes and should not be considered medical advice. Coverage decisions depend on individual medical circumstances and specific insurance plan terms. Always consult with your healthcare provider about treatment options and work directly with your insurance company for coverage determinations. For personalized help with Georgia insurance appeals, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298.

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