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

How to Get Emgality (galcanezumab-gnlm) Covered by Aetna CVS Health in California: Complete Appeals Guide

Answer Box: Getting Emgality Covered by Aetna CVS Health in California

Emgality (galcanezumab-gnlm) requires prior authorization through Aetna CVS Health and must be dispensed through CVS Specialty Pharmacy. You'll need documented failure of at least two standard migraine preventives. Start today by: (1) Having your doctor submit the Medical Exception/Prior Authorization form via the Availity portal or fax to 1-866-237-5512, (2) Gathering records showing failed trials with topiramate, propranolol, or similar preventives, and (3) If denied, you have 180 days to appeal internally, then can request California's Independent Medical Review (IMR) through the DMHC for a binding external decision.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Forms and Submission Portals
  4. Specialty Pharmacy Requirements
  5. Common Denial Reasons and Solutions
  6. Appeals Process in California
  7. Cost-Saving Options
  8. Contact Directory
  9. FAQ

Coverage Requirements at a Glance

Requirement Details Documentation Needed Source
Prior Authorization Required for all plans Medical Exception/PA form Aetna CVS Policy
Step Therapy 2+ preventive failures Clinical notes showing trials/failures CVS Caremark PA Guidelines
Formulary Status Specialty tier (high copay) Insurance verification Aetna Formulary
Dispensing CVS Specialty only Prescription sent to specialty pharmacy CVS Specialty Info
Appeal Deadline 180 days from denial Internal appeal first, then IMR DMHC Appeals

Step-by-Step: Fastest Path to Approval

1. Verify Your Coverage (Patient/Clinic Staff)

Call the member services number on your Aetna ID card to confirm your plan covers specialty medications and identify your specific formulary. Ask about your specialty pharmacy copay tier.

2. Gather Step Therapy Documentation (Clinic)

Collect records showing you've tried and failed (or couldn't tolerate) at least two standard migraine preventives like:

  • Topiramate (Topamax)
  • Propranolol or other beta-blockers
  • Amitriptyline or other tricyclics
  • Valproate

Document specific reasons for discontinuation (side effects, lack of efficacy, contraindications).

3. Complete Prior Authorization Form (Prescriber)

Use Aetna's "Medical Exception/Prior Authorization/Precertification Request for Prescription Medications" form. Include:

  • ICD-10 codes (G43.909 for migraine, unspecified)
  • Migraine frequency (days per month)
  • Prior medication trials with dates and outcomes
  • Clinical rationale for Emgality specifically

Timeline: Standard decisions within 30-45 days; expedited (urgent) within 72 hours.

4. Submit via Electronic Portal or Fax (Prescriber)

  • Preferred: Availity portal or CVS Specialty Central
  • Fax: 1-866-237-5512
  • Phone for questions: 1-808-254-4414

5. Await Decision and Prepare for Specialty Pharmacy

If approved, CVS Specialty will contact you to arrange delivery or pickup. They'll provide injection training and ongoing support.

6. Appeal if Denied (Patient/Prescriber)

File internal appeal within 180 days. If upheld, request California Independent Medical Review (IMR) through DMHC.

7. Escalate to California IMR if Needed

California's IMR has high overturn rates (50-68%) for medically necessary specialty drugs. The process is free and binding on Aetna.

Forms and Submission Portals

Primary Prior Authorization Form

Aetna Medical Exception/Prior Authorization/Precertification Request for Prescription Medications

  • Available through your prescriber's Availity portal account
  • Can be faxed to: 1-866-237-5512
  • Required sections: Patient demographics, diagnosis codes, medication details, clinical justification

Electronic Submission Options

  1. CVS Specialty Central (providers): Dedicated dashboard for specialty medication management
    • Requires individual account setup with work email
    • 24/7 access with real-time benefits verification
    • Contact CVS Specialty representative for access invitation
  2. Availity Portal: Standard provider portal for PA submissions
    • Integrated with most EHR systems
    • Expedites processing compared to fax submission

Required Documentation Checklist

  • Completed PA form with prescriber signature
  • Chart notes documenting migraine frequency and severity
  • Records of prior preventive medication trials
  • Current medication list
  • Relevant lab results or imaging (if applicable)

Specialty Pharmacy Requirements

Mandatory CVS Specialty Dispensing

Emgality must be dispensed through CVS Specialty Pharmacy and cannot be filled at regular retail pharmacies. This is a hard requirement for all Aetna CVS Health plans.

Important California Note: Some California HMO members may have limitations on specialty pharmacy access. Verify your specific plan type.

Enrollment Process

  1. Prescription Routing: Your prescriber sends the prescription directly to CVS Specialty using specialty pharmacy codes
  2. Coverage Verification: CVS Specialty confirms your Aetna benefits and copay
  3. Patient Contact: CVS Specialty calls you to arrange delivery or CVS Pharmacy pickup (where available)
  4. Injection Training: Free training provided on proper self-injection technique

California Contact for CVS Specialty

  • Phone: 1-800-436-7119 (California and Nevada members)
  • General CVS Specialty: 1-866-782-2779

Common Denial Reasons and Solutions

Denial Reason Solution Strategy Required Documentation
"Step therapy not completed" Document 2+ preventive failures Detailed medication history with dates, doses, duration, discontinuation reasons
"Not medically necessary" Strengthen clinical justification Migraine diary, disability impact, headache frequency ≥4 days/month
"Experimental/investigational" Cite FDA approval and guidelines FDA label, American Headache Society guidelines, peer-reviewed studies
"Non-formulary" Request formulary exception Comparative effectiveness data, contraindications to formulary alternatives
From Our Advocates: We've seen many Emgality denials overturned by thoroughly documenting migraine frequency and the specific medical reasons why standard preventives failed. Include exact dates of medication trials and be specific about side effects—"intolerable fatigue affecting work performance" is stronger than just "side effects."

Appeals Process in California

Internal Appeal (First Level)

  • Deadline: 180 days from denial notice
  • Process: Submit written appeal with supporting clinical documentation
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Contact: Use member services number on your ID card

California Independent Medical Review (IMR)

If your internal appeal is denied or you don't receive a response within 30 days, you can request an IMR through California's Department of Managed Health Care.

Key Advantages of California IMR:

  • Free process (no cost to patient)
  • High success rates: 50-68% overturn rate for specialty drug denials
  • Binding decision: Aetna must comply with IMR determination
  • Independent review: Conducted by physicians with relevant specialty expertise

How to Request IMR:

  1. File complaint with DMHC online at healthhelp.ca.gov
  2. Call DMHC Help Center: 888-466-2219
  3. Submit supporting medical records and denial letters
  4. Timeline: 45 days for standard IMR, 7 days for expedited

Cost-Saving Options

Manufacturer Support

Lilly Cares Foundation Patient Assistance Program

  • Income-based free medication for eligible patients
  • Apply at lillycares.com or call 1-833-808-1234

Copay Assistance

Emgality Savings Card

  • Up to $100 off monthly copay for commercially insured patients
  • Available at emgality.com
  • Cannot be combined with government insurance

California State Resources

  • Covered California: Premium subsidies for marketplace plans
  • Medi-Cal: California's expanded Medicaid program
  • Health Consumer Alliance: Free assistance with insurance appeals

Contact Directory

Aetna CVS Health Member Services

  • General: 1-888-792-3862 (TTY: 711)
  • Hours: Monday-Friday 7 AM-11 PM ET; Saturday 7 AM-9:30 PM ET; Sunday 8 AM-6 PM ET
  • Pharmacy: 1-800-238-6279

Prior Authorization Support

  • Fax: 1-866-237-5512
  • Phone: 1-808-254-4414
  • Specialty Drug PA: 1-866-503-0857

CVS Specialty Pharmacy

  • California Members: 1-800-436-7119
  • General: 1-866-782-2779
  • Fax: 1-866-329-2779

California Regulators

  • DMHC Help Center: 888-466-2219
  • Online IMR Application: healthhelp.ca.gov
  • CDI Consumer Hotline: 800-927-4357

FAQ

Q: How long does Aetna CVS Health prior authorization take in California? A: Standard PA decisions take 30-45 days. Expedited reviews for urgent medical situations are completed within 72 hours.

Q: What if Emgality is not on my Aetna formulary? A: You can request a formulary exception with supporting documentation from your prescriber. The request must be decided within 72 hours of receiving your doctor's supporting statement.

Q: Can I get an expedited appeal if my migraines are severe? A: Yes. If waiting for a standard appeal could seriously harm your health, request an expedited review. Aetna must decide within 24 hours of receiving your doctor's supporting statement.

Q: Does California's step therapy apply if I tried preventives in another state? A: Yes, documented medication trials from other states count toward step therapy requirements. Ensure your new California provider has complete medical records.

Q: What happens if Aetna denies my internal appeal? A: You can request an Independent Medical Review (IMR) through California's DMHC. This is a free, binding external review with high success rates for medically necessary treatments.

Q: How much will Emgality cost with Aetna CVS Health? A: Costs vary by plan, but as a specialty medication, expect high copays ($100-500+ per month). Check your specific plan's specialty tier copay and consider manufacturer copay assistance.

Q: Can I fill Emgality at my local CVS pharmacy? A: Only at select CVS locations that handle specialty medications. Most Emgality prescriptions are delivered by CVS Specialty Pharmacy directly to your home.

Q: What should I do if CVS Specialty delays my medication? A: Contact CVS Specialty immediately at 1-800-436-7119. For urgent situations, ask your prescriber to request an emergency supply while resolving delays.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with each payer's specific requirements, pulling the right clinical evidence and meeting procedural deadlines.

If you need help navigating complex prior authorization requirements or appealing an Emgality denial, Counterforce Health's automated system can identify the exact denial basis and generate compelling appeals that address Aetna CVS Health's specific coverage criteria for CGRP inhibitors.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan directly. For personalized assistance with California insurance appeals, contact the DMHC Help Center at 888-466-2219.

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