By Counterforce Health Team in Filsuvez (birch triterpenes topical gel) —

How to Get Filsuvez (Birch Triterpenes Gel) Approved by Aetna CVS Health in New Jersey: Forms, Appeals & State Protections

Answer Box: Getting Filsuvez Approved by Aetna CVS Health in New Jersey

Filsuvez (birch triterpenes topical gel) requires prior authorization from Aetna CVS Health for epidermolysis bullosa patients ≥6 months old. Your fastest path: 1) Have your EB specialist complete the Medical Exception/Prior Authorization form with genetic testing confirmation and wound documentation, 2) Submit via Availity portal or fax to 1-888-267-3277, 3) If denied, you have 180 days to appeal internally, then can file external review with New Jersey's IHCAP program through Maximus Federal Services (1-888-393-1062).

Table of Contents

Start Here: Verify Your Plan Coverage

Before requesting Filsuvez coverage, confirm your specific Aetna plan details. Not all Aetna products follow the same prior authorization process.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all plans Check member portal or call member services Aetna PA Lists
Age Restriction Patient must be ≥6 months old FDA label requirement Birth certificate/medical records
Diagnosis Junctional or dystrophic EB confirmed Genetic testing results COL7A1, LAMA3, LAMB3 mutations
Prescriber Dermatologist or EB specialist Provider credentials Board certification required
Wound Criteria Partial-thickness wounds ≥21 days Clinical documentation Photos, measurements, notes
Note: Self-funded employer plans may have different requirements. Check your Summary Plan Description or contact HR benefits.

Required Forms and Documentation

Primary Form

Download the current Medical Exception/Prior Authorization/Precertification Request for Prescription Medications (last updated October 2025).

Essential Documentation Checklist

  • Genetic Testing Results: Confirming junctional or dystrophic EB with specific mutations
  • Clinical Notes: From dermatologist or EB specialist within past 90 days
  • Wound Assessment: Photos, measurements, duration (≥21 days), infection status
  • Treatment History: Prior therapies tried, outcomes, side effects, contraindications
  • Birth Certificate/Age Verification: For patients near the 6-month minimum
  • Prescriber Credentials: Board certification in dermatology or relevant specialty

Clinician Corner: Medical Necessity Letter

Your medical necessity letter should address:

  • Diagnosis confirmation with ICD-10 codes (Q81.1 for dystrophic EB, Q81.2 for junctional EB)
  • Prior treatment failures with specific dates, medications, and outcomes
  • Clinical rationale for Filsuvez based on FDA approval and EB specialty guidelines
  • Wound characteristics that meet FDA-approved indications
  • Treatment goals and expected outcomes with monitoring plan

Include citations from the FDA prescribing information and relevant dermatology society guidelines.

Submission Portals and Methods

  • Portal: Availity.com - Aetna's preferred electronic submission method
  • Turnaround: Typically faster than fax submissions
  • Upload: All supporting documentation directly in portal

Fax Submission

  • Commercial Plans: 1-888-267-3277
  • Medicare Advantage Part B: 1-844-268-7263
  • Include: Completed PA form plus all supporting documentation
  • Cover Sheet: Include member ID, prescriber NPI, and "URGENT" if expedited review needed

Phone Support

  • Commercial Plans: 1-866-752-7021
  • Medicare Advantage: 1-866-503-0857
Tip: Keep copies of all submissions and note confirmation numbers for tracking.

Specialty Pharmacy Coordination

Filsuvez is typically dispensed through CVS Caremark Specialty Pharmacy as part of Aetna's integrated network.

Onboarding Process

  1. Prescription Transfer: Call CVS Specialty at 1-800-237-2767 or initiate online
  2. Clinical Team Assignment: You'll be assigned nurses and pharmacists familiar with EB
  3. Insurance Verification: CVS coordinates with Aetna for coverage and copay determination
  4. Delivery Setup: Temperature-controlled shipping to your preferred address
  5. Ongoing Support: Refill reminders, adherence monitoring, and clinical questions

Required Information for Transfer

  • Current prescription label
  • Insurance card information
  • Preferred delivery address
  • Emergency contact information

Counterforce Health helps patients navigate complex specialty pharmacy requirements and can assist with documentation if your transfer encounters coverage issues.

Appeals Process in New Jersey

If your initial prior authorization is denied, New Jersey provides robust appeal protections.

Internal Appeals with Aetna

  • Timeline: You have 180 days from denial to file internal appeal
  • Levels: Two levels of internal review required
  • Expedited: Available for urgent medical situations (72-hour decision)
  • Standard: 30-day decision timeline

Step-by-Step Internal Appeal Process

  1. Request Appeal Form: Contact Aetna member services or download from member portal
  2. Gather Evidence: Medical records, specialist opinions, treatment failure documentation
  3. Submit Complete Package: Include all supporting documentation with appeal form
  4. Track Timeline: Follow up if decision isn't received within stated timeframes
  5. Document Everything: Keep copies and confirmation numbers

New Jersey IHCAP External Review

New Jersey's Independent Health Care Appeals Program (IHCAP) provides external review after internal appeals are exhausted.

IHCAP Process Overview

  • Operator: Maximus Federal Services manages external reviews for New Jersey
  • Eligibility: Fully insured New Jersey plans (not self-funded employer plans)
  • Timeline: Must file within 4 months of final internal denial
  • Decision: Binding on Aetna if overturned

Filing External Appeal

Decision Timelines

  • Standard Review: Decision within 45 calendar days
  • Expedited Review: Decision within 48 hours for urgent situations
  • Preliminary Review: Maximus confirms eligibility within 5 business days
From Our Advocates: We've seen several EB patients successfully overturn Aetna denials through IHCAP by submitting comprehensive genetic testing results and detailed wound progression photos. The key is demonstrating that standard wound care hasn't provided adequate healing after 21+ days of appropriate treatment.

Support and Contact Information

Patient Support Lines

  • Aetna Member Services: Number on back of insurance card
  • CVS Caremark Specialty: 1-800-237-2767
  • New Jersey IHCAP Hotline: 1-888-393-1062
  • NJ Department of Banking and Insurance: 1-800-446-7467

Provider Support

  • Aetna Provider Services: Availity.com portal
  • Prior Authorization Status: 1-866-752-7021 (commercial)
  • Peer-to-Peer Review: Available upon request for complex cases

Manufacturer Support

  • Chiesi Global Rare Diseases: Check manufacturer website for patient assistance programs
  • EB Medical Research Foundation: May provide resources and advocacy support

When complex prior authorization issues arise, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to payer policies.

FAQ

How long does Aetna prior authorization take for Filsuvez in New Jersey? Standard decisions typically take 10-15 calendar days. Expedited reviews for urgent situations are completed within 48-72 hours.

What if Filsuvez isn't on my Aetna formulary? You can request a formulary exception with documentation of medical necessity and failure of preferred alternatives. The same prior authorization process applies.

Can I request an expedited appeal if my wounds are worsening? Yes. Both internal appeals with Aetna and external IHCAP reviews offer expedited timelines for urgent medical situations.

Does step therapy apply to Filsuvez for EB patients? Step therapy requirements vary by plan. Document any prior wound care treatments that failed to achieve healing to support exception requests.

What happens if I move out of New Jersey during an appeal? IHCAP external review rights are based on where your plan is regulated, not your current address. Complete any pending New Jersey appeals before coverage transfers.

Can my doctor file the IHCAP appeal for me? Yes. Providers can file external appeals on behalf of patients with proper consent and authorization forms.

Are there costs for external appeals in New Jersey? No. Insurers pay all costs for IHCAP external reviews. You pay nothing for the independent review process.

What documentation is most important for approval? Genetic testing confirming EB subtype, clinical photos showing wound characteristics, and detailed treatment history are typically the strongest supporting evidence.

Sources & Further Reading

This guide is for informational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and contact official sources to verify current forms, deadlines, and requirements. For additional support with complex insurance appeals, visit Counterforce Health.

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