By Counterforce Health Team in Emgality (galcanezumab-gnlm) —

How to Get Emgality (galcanezumab) Covered by Aetna CVS Health in Pennsylvania: Complete Guide to Forms, Appeals, and Resources

Answer Box: Getting Emgality Approved by Aetna CVS Health in Pennsylvania

Fastest path to approval: Submit Aetna's "Medical Exception/Prior Authorization/Precertification Request for Prescription Medications" form via fax (1-888-267-3277) or Availity portal. Include documentation of failed step therapy (typically 2+ preventive medications like topiramate or beta-blockers), complete migraine history, and ICD-10 diagnosis codes. If denied, appeal within 180 days, then use Pennsylvania's external review program within 4 months for binding decisions. Start today: Call Aetna Member Services (number on your ID card) to verify PA requirements and download current forms.

Table of Contents

  1. Start Here: Verify Your Plan & Requirements
  2. Prior Authorization Forms & Documentation
  3. Submission Portals & Methods
  4. Specialty Pharmacy Enrollment
  5. Appeals Process & Pennsylvania External Review
  6. Support Contacts & Case Management
  7. Common Denial Reasons & Solutions
  8. Cost Support & Patient Assistance
  9. FAQ: Emgality Coverage with Aetna CVS Health

Start Here: Verify Your Plan & Requirements

Before requesting Emgality (galcanezumab) coverage, confirm your specific Aetna plan type and current formulary status:

Step 1: Check Your Plan Type

  • Commercial/Employer plans: Call Member Services (number on ID card)
  • Medicare Advantage: Call 1-855-335-1407 (TTY: 711)
  • Aetna Better Health PA (Medicaid): Call 1-800-822-2447 (TTY: 711)

Step 2: Verify Formulary Status Log into your Aetna member portal or ask Member Services about Emgality's formulary tier and any restrictions. Most Aetna plans require prior authorization for CGRP inhibitors like Emgality due to their specialty status and cost (~$741.69 per 120-mg pen).

Note: Emgality is typically considered a specialty medication requiring dispensing through CVS Specialty or approved specialty pharmacies.

Prior Authorization Forms & Documentation

Required Form

Use Aetna's "Medical Exception/Prior Authorization/Precertification Request for Prescription Medications" form, last updated September 2025. Download from Aetna's provider portal or access via PrescriberPoint.

Clinical Documentation Checklist

Your prescriber must include:

  • Diagnosis: Primary diagnosis with ICD-10 code (G43.909 for migraine, unspecified)
  • Step Therapy Documentation: Complete list of prior preventive medications tried, including:
    • Topiramate, propranolol, or other beta-blockers
    • Amitriptyline or other tricyclics
    • Dates of therapy, dosages, duration of trials
    • Reasons for discontinuation (lack of efficacy, adverse effects, contraindications)
  • Migraine History: Frequency of headache days per month, functional impairment
  • Treatment Goals: Expected outcomes with Emgality therapy
  • Dosing Rationale: 240 mg loading dose, then 120 mg monthly for migraine prevention

Clinician Corner: Medical Necessity Letter

Essential elements for approval:

  1. Clinical problem: Document migraine frequency, severity, and impact on daily functioning
  2. Prior treatments: List specific medications, dosages, durations, and outcomes
  3. Contraindications: Note any medical reasons why preferred alternatives aren't suitable
  4. Guideline support: Reference FDA labeling for Emgality and American Headache Society guidelines
  5. Monitoring plan: Describe follow-up schedule and response assessment

Submission Portals & Methods

Primary Submission Options

Online Portal (Recommended)

  • Availity: www.availity.com - Fastest processing and status tracking
  • Requires provider registration and secure login

Fax Submission

  • Specialty medications: 1-888-267-3277
  • Non-specialty drugs: 1-877-269-9916
  • Include cover sheet with member ID, prescriber NPI, and "URGENT" if expedited review needed

Phone Support

  • CVS Caremark PA Department: 1-800-294-5979 (Mon-Fri, 8 AM–6 PM CST)
  • For questions about forms, status updates, or clinical peer review requests
Tip: Submit via Availity when possible - it provides real-time status updates and faster processing than fax submissions.

Specialty Pharmacy Enrollment

Since Emgality requires specialty pharmacy dispensing, you'll need to enroll with CVS Specialty:

Enrollment Process

  1. Access Portal: Visit CVS Specialty and create patient account
  2. Transfer Existing Rx: If switching from another pharmacy, select "transfer prescription" and provide previous pharmacy details
  3. New Prescriptions: Have your prescriber send directly to CVS Specialty with proper specialty pharmacy codes
  4. Insurance Verification: CVS Specialty will verify Aetna coverage and PA status
  5. Delivery Setup: Choose home delivery or CVS Pharmacy pickup (where available)

Required Information

  • Aetna member ID and insurance card
  • Prescriber contact information
  • Preferred delivery address and contact method
  • Emergency contact information

Appeals Process & Pennsylvania External Review

Internal Appeals with Aetna

Timeline: 180 days from denial to file appeal Methods:

  • Fax: 1-855-330-1716 (medical exceptions)
  • Mail: Aetna Provider Resolution Team, PO Box 14020, Lexington, KY 40512
  • Online: Via Availity portal

Required Documentation:

  • Original denial letter
  • Updated medical necessity letter addressing specific denial reasons
  • Additional clinical evidence (specialist notes, imaging, lab results)
  • Aetna appeal form

Pennsylvania External Review Program

If Aetna upholds the denial after internal appeals, Pennsylvania's Independent External Review Program offers binding review:

Eligibility: Must have Final Adverse Benefit Determination letter from Aetna Timeline: 4 months from final denial to request external review Submission: Pennsylvania Insurance Department portal

Success Rate: Approximately 50% of external reviews in Pennsylvania result in coverage approval

Expedited Reviews

For urgent situations where delay could harm your health:

  • Internal (Aetna): 72 hours for decision
  • External (PA): 72 hours from assignment to review organization
  • Requires physician attestation of medical urgency

Support Contacts & Case Management

Aetna Member Services

  • General inquiries: Number on your Aetna ID card
  • Medicare members: 1-855-335-1407 (TTY: 711)
  • Medicaid (Aetna Better Health PA): 1-800-822-2447 (TTY: 711)
  • External review questions: 1-877-848-5855

Case Management Services

Request a case manager through Member Services if you have:

  • Multiple denial appeals
  • Complex medical conditions
  • Coordination needs between providers
  • Questions about specialty pharmacy processes

Pennsylvania Consumer Assistance

  • PA Insurance Department Consumer Services: Available via pa.gov for appeal guidance
  • Pennsylvania Health Law Project: Free assistance for complex appeals, especially for low-income individuals

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Step therapy not completed Document failed trials of 2+ preventives Medication list with dates, doses, outcomes
Not medically necessary Strengthen clinical justification Updated letter citing guidelines, functional impact
Non-formulary status Request formulary exception Medical necessity for Emgality over alternatives
Quantity limits exceeded Justify dosing regimen FDA labeling, clinical rationale for frequency
Diagnosis not covered Clarify indication ICD-10 codes, specialist consultation notes
From our advocates: "We've seen many Emgality appeals succeed when prescribers document specific functional improvements expected (like reduction from 15 to 8 headache days per month) rather than general statements about migraine prevention. Quantifiable treatment goals strengthen medical necessity arguments significantly."

Cost Support & Patient Assistance

Manufacturer Support

  • Lilly Cares Foundation: Patient assistance for qualifying low-income individuals
  • Emgality Savings Card: May reduce copays for commercially insured patients (verify current terms)

Pennsylvania State Programs

  • PACE/PACENET: Prescription assistance for seniors 65+ meeting income requirements
  • Pennsylvania Department of Health: Additional resources via state health programs

FAQ: Emgality Coverage with Aetna CVS Health

Q: How long does Aetna prior authorization take for Emgality in Pennsylvania? A: Standard PA decisions typically take 30-45 days. Expedited reviews (when medically urgent) are completed within 72 hours.

Q: What if Emgality is non-formulary on my Aetna plan? A: Request a formulary exception by demonstrating medical necessity and failure of formulary alternatives. Include documentation of contraindications or inadequate response to preferred options.

Q: Can I request an expedited appeal if I'm out of medication? A: Yes, if delay would seriously jeopardize your health. Your prescriber must provide written attestation of medical urgency for expedited processing.

Q: Does step therapy apply if I failed preventives with another insurer? A: Medical records from previous insurers documenting failed therapies should satisfy step therapy requirements. Ensure your prescriber includes this history in the PA request.

Q: What happens if Pennsylvania external review approves coverage? A: The decision is binding on Aetna. They must provide coverage immediately, including retroactive coverage if you paid out-of-pocket during the appeal.

Q: Can I use CVS Specialty if I live in rural Pennsylvania? A: Yes, CVS Specialty provides home delivery throughout Pennsylvania. Some locations may offer pickup at local CVS Pharmacy stores.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters, identifies the specific coverage criteria, and generates evidence-backed appeals aligned to each payer's requirements - including Aetna's PA policies for specialty medications like Emgality.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and procedures may change. Always verify current requirements with Aetna and consult your healthcare provider for medical decisions. For personalized assistance with appeals, consider consulting Counterforce Health or other qualified advocacy services.

Sources & Further Reading

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