By Counterforce Health Team in Emflaza (deflazacort) —

How to Get Emflaza (Deflazacort) Covered by Aetna CVS Health in Pennsylvania: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Emflaza Covered by Aetna CVS Health in Pennsylvania

Emflaza (deflazacort) requires prior authorization from Aetna CVS Health for Duchenne muscular dystrophy (DMD) patients. Submit genetic testing confirming DMD diagnosis, patient age ≥5 years, and dosing ≤0.9 mg/kg/day through your provider's Aetna portal. If denied, appeal within 180 days using Pennsylvania's new external review process—roughly 50% of appeals succeed. Start by calling Aetna CVS Customer Care at 888-321-3124 to check formulary status and initiate prior authorization today.

Table of Contents

Understanding Your Denial Letter

When Aetna CVS Health denies Emflaza coverage, your Explanation of Benefits (EOB) or denial letter will contain specific reason codes. The most common reasons include:

  • Prior authorization required (not submitted or incomplete)
  • Step therapy not satisfied (must try prednisone/prednisolone first)
  • Non-formulary drug (requires formulary exception)
  • Dosing exceeds limits (above 0.9 mg/kg/day without justification)
  • Age restriction (patient under 5 years old)
  • Insufficient medical necessity (DMD diagnosis not confirmed)

Look for the appeal deadline—typically 180 days for commercial plans. Note whether this is a medical benefit denial (processed by Aetna) or pharmacy benefit denial (processed by CVS Caremark).

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed Source
DMD Diagnosis Genetic testing or muscle biopsy confirmation Lab results showing specific mutation Aetna DMD Policy
Age ≥5 years Patient must be at least 5 years old Birth certificate, medical records PA Health & Wellness Policy
Dosing ≤0.9 mg/kg/day Weight-based dose calculation Current weight, prescribed dose PA Health & Wellness Policy
Prior Authorization Required for all DMD therapies Completed PA form via provider Aetna Provider Portal
Step Therapy May require prednisone trial first Documentation of failure/intolerance CVS Caremark Policy

Step-by-Step: Fastest Path to Approval

1. Check Formulary Status (Patient/Caregiver)

Call Aetna CVS Customer Care at 888-321-3124 to confirm whether Emflaza is covered on your specific plan's formulary. If non-formulary, request information about the exception process.

2. Gather Required Documentation (Clinic)

Your healthcare provider needs:

  • Genetic testing results confirming DMD diagnosis
  • Current weight and calculated dose (≤0.9 mg/kg/day)
  • Documentation of any prior corticosteroid trials
  • ICD-10 code G71.0 (Duchenne muscular dystrophy)

3. Submit Prior Authorization (Provider)

Submit through the Aetna provider portal or fax completed forms. Include all supporting documentation. Standard processing time is 30-45 days.

4. Request Expedited Review if Urgent (Provider)

If patient's condition is deteriorating, request expedited review (typically 72 hours). Call Aetna's provider line to initiate.

5. Monitor Decision (Patient/Clinic)

Track the request status through the provider portal. Aetna will notify both provider and patient of the decision by mail.

6. Appeal if Denied (Patient/Provider)

If denied, you have 180 days to file an internal appeal with additional documentation.

7. External Review if Needed (Patient)

After exhausting internal appeals, file with Pennsylvania Insurance Department within 4 months of final denial.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Age restriction (under 5) Submit birth certificate showing age ≥5 Birth certificate, current medical records
Dosing exceeds 0.9 mg/kg/day Provide clinical justification or adjust dose Weight-based calculation, medical necessity letter
Step therapy not met Document prednisone failure/intolerance Side effect records, treatment timeline
DMD diagnosis not confirmed Submit genetic testing results Lab reports, muscle biopsy results
Non-formulary status Request formulary exception Trial-and-failure documentation, contraindications

Medical Necessity Documentation

Clinician Corner: Letter of Medical Necessity Checklist

When writing a medical necessity letter for Emflaza, include:

Patient Information:

  • Confirmed DMD diagnosis with genetic testing results
  • Age at symptom onset (typically before age 5)
  • Current age (must be ≥5 years)
  • Current functional status and motor assessments

Clinical Rationale:

  • FDA approval for DMD in patients ≥2 years
  • Superior side effect profile compared to prednisone/prednisolone
  • Weight-based dosing calculation (≤0.9 mg/kg/day)
  • Expected benefits: improved motor function, delayed disease progression

Prior Treatments:

  • Previous corticosteroid trials and outcomes
  • Documented side effects or contraindications to alternatives
  • Functional decline without corticosteroid therapy

Supporting Evidence:

  • Reference FDA labeling and DMD treatment guidelines
  • Attach genetic testing results and functional assessments
  • Include current weight and dosing justification
From Our Advocates: We've seen that appeals including both genetic testing confirmation and detailed functional assessments have higher success rates. Providers who document specific motor milestones and progression timelines alongside genetic results often see faster approvals, particularly when they clearly explain why Emflaza's side effect profile is preferable to prednisone for their specific patient.

Appeals Process in Pennsylvania

Pennsylvania launched its Independent External Review Program in January 2024, giving patients a powerful new tool to overturn insurance denials.

Internal Appeal Process (Aetna)

  1. Submit within 180 days of denial
  2. Standard review: 30 days for service denials, 60 days for reimbursement
  3. Expedited review: 72 hours for urgent cases
  4. Include additional medical documentation and provider letter

Pennsylvania External Review Process

After receiving Aetna's Final Adverse Benefit Determination:

  1. Submit request within 4 months via Pennsylvania Insurance Department portal
  2. No cost to patients
  3. Timeline: 45 days for standard review, 72 hours for expedited
  4. Success rate: Approximately 50% of appeals overturned in first year
  5. Binding decision on Aetna CVS Health

Required Documents for External Review

  • Final Adverse Benefit Determination letter from Aetna
  • All internal appeal correspondence
  • Medical records supporting Emflaza necessity
  • Provider letter of medical necessity
  • Genetic testing results confirming DMD

For help with the process, contact Pennsylvania Insurance Department Consumer Services at 1-877-881-6388.

Templates and Scripts

Patient Phone Script for Aetna CVS Health

"Hello, I'm calling about prior authorization for Emflaza for my [child/family member] with Duchenne muscular dystrophy. The member ID is [number]. Can you tell me if Emflaza is on formulary for our plan and what documentation is needed for approval?"

Provider Peer-to-Peer Request Script

"I'm requesting a peer-to-peer review for [patient name] regarding denial of Emflaza for confirmed DMD. The patient meets all FDA criteria—genetic testing confirms DMD, age is [X] years, and dosing is [X] mg/kg/day. Can we schedule a call with your medical director to discuss the medical necessity?"

Medical Necessity Letter Template

[Provider Letterhead]
[Date]

Aetna CVS Health
Prior Authorization Department
[Address from denial letter]

Re: [Patient Name], DOB: [Date], Policy ID: [Number]
Request: Emflaza (deflazacort) for Duchenne Muscular Dystrophy

Dear Medical Director,

I am writing to request coverage for Emflaza (deflazacort) for my patient [Name], a [age]-year-old with genetically confirmed Duchenne muscular dystrophy.

DIAGNOSIS: DMD confirmed by genetic testing on [date], showing [specific mutation]. Symptoms onset at age [X] with [specific symptoms].

MEDICAL NECESSITY: Emflaza is FDA-approved for DMD patients ≥2 years. Current prescription: [dose] mg/kg/day (≤0.9 mg/kg/day limit). Patient requires corticosteroid therapy to maintain motor function and delay disease progression.

PRIOR TREATMENTS: [If applicable] Previous trial of prednisone resulted in [specific side effects/contraindications]. Emflaza offers superior side effect profile for long-term DMD management.

CLINICAL JUSTIFICATION: Without corticosteroid therapy, patients with DMD experience rapid motor decline and loss of ambulation. Emflaza has demonstrated efficacy in preserving motor function while minimizing growth suppression and behavioral side effects compared to prednisone.

Enclosed: Genetic testing results, current functional assessments, weight-based dosing calculation.

Please contact me at [phone] for any additional information.

Sincerely,
[Provider Name, Credentials]
[NPI Number]

Cost Savings Options

Manufacturer Support

  • PTC Cares Patient Navigation: Free support program helping with insurance authorization and appeals
  • Website: emflaza.com/ptc-cares-helps
  • Phone: Available through PTC Therapeutics

Copay Assistance

Check with PTC Therapeutics for current copay card programs and eligibility requirements for commercially insured patients.

Foundation Support

Organizations like the Parent Project Muscular Dystrophy may offer grant assistance for DMD therapies. Contact them for current programs.

When navigating complex insurance denials and appeals, Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The 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, pulling the right citations and clinical evidence to strengthen your case.

When to Escalate

File a Complaint with Pennsylvania Regulators

If Aetna CVS Health violates appeal timelines or procedures, contact:

  • Pennsylvania Insurance Department: 1-877-881-6388
  • Online complaint form: Available at pa.gov
  • Required documents: Denial letters, appeal correspondence, timeline documentation

Federal Options

For Medicare plans, contact 1-800-MEDICARE for guidance on appeals and complaints.

FAQ

How long does Aetna CVS Health prior authorization take in Pennsylvania? Standard prior authorization decisions take 30-45 days. Expedited reviews for urgent cases are typically completed within 72 hours.

What if Emflaza is non-formulary on my plan? You can request a formulary exception by demonstrating trial-and-failure of formulary alternatives or documented contraindications. Call 888-321-3124 to start the process.

Can I request an expedited appeal? Yes, if your health is in serious jeopardy or your condition is rapidly deteriorating. Your provider can request expedited review, typically decided within 72 hours.

Does step therapy apply if I've tried prednisone outside Pennsylvania? Yes, documented trials from any state typically satisfy step therapy requirements. Provide complete medical records showing the trial and any adverse effects.

What happens if my external review is approved? Aetna CVS Health must immediately provide coverage, including retroactive coverage if you paid out-of-pocket during the appeal process.

How much does Emflaza cost without insurance? Discount card prices show approximately $9-12 per 6mg tablet, though actual costs vary by strength and pharmacy. Monthly costs can be substantial without coverage.

Can I get help with the appeals process? Yes, Counterforce Health provides specialized support for insurance denials and appeals, helping to create targeted, evidence-backed appeals that address the specific reasons for denial.

What documentation do I need for a successful appeal? Key documents include genetic testing confirming DMD, current weight and dosing calculations, any prior corticosteroid trials and outcomes, functional assessments, and a detailed medical necessity letter from your provider.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan for guidance specific to your situation. For additional help with insurance appeals, contact the Pennsylvania Insurance Department at 1-877-881-6388 or visit pa.gov for official resources.

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