By Counterforce Health Team in Gattex (teduglutide) —

How to Get Gattex (Teduglutide) Covered by Aetna CVS Health in Ohio: PA Requirements, Appeals & Forms

Answer Box: Getting Gattex Covered by Aetna CVS Health in Ohio

Aetna CVS Health covers Gattex (teduglutide) on specialty tiers with prior authorization required for short bowel syndrome patients dependent on parenteral nutrition ≥3 days weekly for ≥12 months. Submit PA via CVS Specialty at (866) 752-7021 with SBS diagnosis, PN logs, gastroenterologist involvement, and recent colonoscopy. If denied, appeal within 60 days to Aetna Better Health Ohio (1-833-928-1259), then request external review within 30 days through Ohio's Independent Review Organization system.

First step today: Call CVS Specialty to confirm your formulary tier and gather required PA documentation.

Table of Contents

  1. Plan Types & Coverage Differences
  2. Formulary Status & Tiers
  3. Prior Authorization Requirements
  4. CVS Specialty Pharmacy Process
  5. Common Denial Reasons & Solutions
  6. Appeals Process in Ohio
  7. Cost-Share Dynamics
  8. When to Escalate
  9. FAQ

Plan Types & Coverage Differences

Aetna offers several plan types in Ohio, each with different network restrictions and referral requirements that affect your Gattex coverage path:

Commercial Plans:

  • HMO: Requires PCP referrals to gastroenterology specialists; in-network only except emergencies
  • PPO: No referrals needed; allows out-of-network care at higher cost-sharing
  • EPO: In-network only with larger provider networks than HMO; may or may not require PCP referrals

Medicaid Managed Care: Aetna Better Health of Ohio serves MyCare Ohio members with integrated Medicare-Medicaid benefits. Your care manager coordinates prior authorizations and specialist referrals at no monthly premium cost.

Note: All plan types require the same PA process for Gattex through CVS Specialty, but referral pathways to gastroenterology differ.

Formulary Status & Tiers

Gattex appears on Aetna's 2025 specialty formularies as a preferred specialty or non-preferred specialty medication, depending on your specific plan. The drug requires:

  • Prior authorization for all new starts and renewals
  • CVS Specialty Pharmacy dispensing exclusively
  • Medical necessity documentation for short bowel syndrome

No FDA-approved alternatives exist for teduglutide, though some plans may require trials of optimized enteral nutrition strategies before approval.

Prior Authorization Requirements

Coverage at a Glance

Requirement What It Means Where to Find It Timeline
SBS Diagnosis Short bowel syndrome with ICD-10 codes Medical records, specialist notes Baseline
PN Dependence ≥3 days/week for ≥12 months (adults) PN logs, infusion records 12+ months documented
Specialist Involvement Gastroenterologist consultation/management Referral, consultation notes Recent (within 6 months)
GI Evaluation Colonoscopy (adults) or fecal occult blood test Procedure reports Within 6 months
Dosing Limits 0.05 mg/kg/day max (adults) Prescription, clinical notes Per FDA labeling

Initial Approval Criteria

Based on Aetna's clinical policy, Gattex requires:

  1. Confirmed SBS diagnosis with appropriate ICD-10 coding
  2. Parenteral nutrition dependence documented ≥12 months for adults
  3. PN frequency of at least 3 days per week
  4. Gastroenterology involvement in care management
  5. Recent GI evaluation ruling out contraindications
  6. Age ≥1 year for pediatric patients

CVS Specialty Pharmacy Process

Patient Enrollment Steps

  1. Provider E-Prescribing: Your doctor sends prescriptions directly to CVS Specialty
  2. Coverage Verification: CVS Specialty confirms benefits via (866) 752-7021
  3. Patient Enrollment: Register at cvsspecialty.com or call (888) 493-5386 for CareTeam support
  4. Fulfillment Options: Home delivery or pickup at participating CVS locations

Required Submission Materials

  • PA form completed by prescriber
  • Clinical notes documenting SBS diagnosis and PN dependence
  • PN logs showing frequency and volumes over 12+ months
  • Specialist consultation from gastroenterology
  • Laboratory results and colonoscopy report (if applicable)
Tip: Start the PA process 60-90 days before you need the medication to allow for potential appeals.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
"No documented PN dependence" Submit detailed PN logs 12+ months of infusion records
"Inadequate baseline assessment" Provide comprehensive GI workup Colonoscopy, specialist evaluation
"Failure to optimize enteral nutrition" Document enteral trials and outcomes Nutrition consult notes, failed attempts
"Non-formulary status" File formulary exception Medical necessity letter, no alternatives
"Quantity over limits" Justify dosing per FDA label Weight-based calculations, clinical rationale

Clinician Corner: Medical Necessity Letter Checklist

When writing appeals, include:

  • SBS etiology and anatomical details
  • Prior nutrition optimization attempts and failures
  • Current PN requirements with specific volumes/frequencies
  • Treatment goals for PN reduction or weaning
  • Monitoring plan for efficacy and safety
  • FDA labeling reference for approved indication

Appeals Process in Ohio

Internal Appeals (First Level)

Timeline: 60 calendar days from denial notice Contact Methods:

  • Fax: 1-833-928-1259
  • Phone: 1-833-711-0773 (TTY 711)
  • Mail: Aetna Better Health of Ohio, Grievance System Manager, PO Box 81040, Cleveland, OH 44181
  • Portal: Availity provider portal

Required Documents:

  • Original denial letter or EOB
  • Medical records supporting medical necessity
  • Clear statement of disagreement with denial reason

External Review (Second Level)

Ohio offers external review through Independent Review Organizations (IROs) within 30 days of internal appeal denial. The Ohio Department of Insurance oversees this process with binding decisions.

Key Features:

  • Independent medical experts review your case
  • Expedited review available if delay risks health
  • No cost to patients for the review process
  • Binding decisions on insurance companies

Step-by-Step Appeals Playbook

  1. Gather denial documentation (letter, EOB, policy information)
  2. Collect supporting medical records within 30 days
  3. Submit internal appeal via preferred method with all documentation
  4. Track appeal status through Availity portal or phone
  5. Request peer-to-peer review if available during internal process
  6. File external review within 30 days if internal appeal denied
  7. Contact Ohio Department of Insurance at 1-800-686-1526 for assistance

Cost-Share Dynamics

Gattex costs approximately $46,893 per 30-vial kit, making specialty tier placement crucial for affordability. Your out-of-pocket costs depend on:

  • Specialty tier copay or coinsurance percentage
  • Annual deductible application to specialty medications
  • Out-of-pocket maximum protection

Financial Assistance Options:

  • Takeda Patient Assistance Program for eligible patients
  • Copay assistance cards for commercially insured patients
  • State pharmaceutical assistance programs in Ohio
Note: Medicaid patients through Aetna Better Health typically have $0 copays for covered specialty medications.

When to Escalate

Contact the Ohio Department of Insurance if you experience:

  • Unreasonable delays in appeal processing
  • Refusal to accept external review requests
  • Procedural violations during appeals
  • Discrimination in coverage decisions

Ohio DOI Consumer Hotline: 1-800-686-1526 External Review Information: Available at insurance.ohio.gov

For complex cases requiring specialized support, Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with payer requirements.

Frequently Asked Questions

How long does Aetna CVS Health PA take in Ohio? Standard prior authorizations typically take 24-72 hours, while expedited reviews for urgent cases are completed within 72 hours.

What if Gattex is non-formulary on my plan? File a formulary exception with medical necessity documentation showing no suitable alternatives exist for your SBS condition.

Can I request an expedited appeal? Yes, if delays would seriously jeopardize your health. Both internal appeals and external reviews offer expedited timelines.

Does step therapy apply to Gattex? Some plans may require documentation of optimized enteral nutrition attempts before approving teduglutide, though no direct therapeutic alternatives exist.

What happens if I miss appeal deadlines? Ohio law provides some flexibility for "good cause" delays, but always submit appeals as soon as possible after denial.

Can I continue Gattex during appeals? Request emergency supplies from CVS Specialty while increasing PN support as a bridge therapy during the appeals process.

From Our Advocates: "We've seen Ohio patients successfully overturn Gattex denials by focusing on detailed PN logs and specialist documentation. The key is showing clear medical necessity with objective data about nutrition dependence. External review through Ohio's IRO system has proven particularly effective when internal appeals fail to recognize the severity of short bowel syndrome."

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions are made individually by insurance companies based on medical necessity and plan benefits. Always consult with your healthcare provider and insurance company for personalized guidance. For additional help with insurance appeals in Ohio, contact the Ohio Department of Insurance Consumer Services Division at 1-800-686-1526.

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