By Counterforce Health Team in Gattex (teduglutide) —

How to Get Gattex (Teduglutide) Covered by Aetna CVS Health in Virginia: Forms, Appeals, and Provider Resources

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

Eligibility: Adults with short bowel syndrome dependent on parenteral nutrition ≥12 months, receiving support ≥3 times weekly. Fastest path: Submit prior authorization through Aetna provider portal with baseline parenteral nutrition logs and specialist attestation. Start today: Call CVS Specialty at 1-866-814-5506 to begin enrollment while your doctor gathers documentation. If denied, you have 180 days to appeal internally, then 120 days for Virginia external review.

Table of Contents

Start Here: Verify Your Plan and Find Forms

Before submitting any requests, confirm you have an Aetna CVS Health plan that covers specialty medications. Call member services at 1-800-279-1878 to verify:

  • Your specific plan type (commercial, Medicare Advantage, Medicaid)
  • Whether Gattex requires prior authorization
  • Your current formulary tier for teduglutide
  • Any applicable quantity limits or site-of-care restrictions
Tip: Ask specifically about "CVS Caremark" or "CVS Specialty" handling, as these divisions manage most specialty drug approvals for Aetna plans.

Coverage at a Glance

Requirement Details Documentation Needed Timeline
PA Required Yes, for all plans Specialist attestation, PN logs 30-45 days standard
Formulary Status Specialty tier (verify with plan) Medical necessity letter N/A
Step Therapy May apply Prior therapy failures Include in PA
Baseline PN Dependency ≥12 months, ≥3x weekly Volume logs (L/week) Ongoing monitoring
Age Requirements Adults and pediatric Age-appropriate criteria Per FDA labeling
Site of Care May be restricted Administration plan Specify in request

Source: Aetna Gattex Coverage Policy

Prior Authorization Forms and Requirements

Standard PA Submission

Aetna accepts prior authorization requests through multiple channels. Download the current PA request form and fax to 1-844-956-1191 or submit online through the Availity provider portal.

Required Clinical Documentation

For Gattex approval, include:

Adult Patients (≥18 years):

  • Documented SBS diagnosis with ICD-10 code
  • Baseline parenteral nutrition dependency ≥12 months
  • Current PN/IV fluid support ≥3 times per week
  • Volume of parenteral support in liters per week
  • Previous attempts at enteral nutrition optimization

Pediatric Patients (<18 years):

  • PN/IV fluids accounting for ≥30% of caloric/fluid needs
  • Age-appropriate dosing calculations
  • Pediatric gastroenterology consultation notes

Medical Necessity Letter Checklist

Your prescriber should address:

✓ Problem statement: SBS diagnosis and current PN dependency
✓ Prior treatments: Failed enteral strategies, surgical history
✓ Clinical rationale: Why teduglutide is medically necessary
✓ Guideline support: FDA labeling for SBS indication
✓ Monitoring plan: PN reduction targets and reassessment schedule

Source: Aetna SBS Coverage Criteria

Submission Portals and Upload Requirements

Online Submission Options

Availity Provider Portal

  • Primary portal for Virginia Aetna providers
  • Upload supporting documents directly
  • Track PA status in real-time
  • Requires provider registration

Phone Submissions

  • Call 1-800-279-1878 (TTY: 711)
  • Available 24/7 for after-hours voicemail
  • Have member ID and NPI ready

Document Upload Requirements

When submitting electronically:

  • File formats: PDF preferred, JPG/PNG accepted
  • Size limits: 10MB per file maximum
  • Required attachments: Current visit notes, lab results, prior therapy documentation
  • Naming convention: Use patient last name and date for easy identification

Fax Numbers and Mail Addresses

Key Fax Numbers for Virginia

Purpose Fax Number Notes
Prior Authorization 1-844-956-1191 Standard PA requests
Specialty Drug Appeals 1-888-836-0730 For specialty drug list medications
Claims Appeals 1-866-669-2459 Post-denial appeals
CVS Specialty Enrollment 1-800-323-2445 Pharmacy enrollment forms

Cover Sheet Tips

Include on all fax submissions:

  • Patient name and member ID
  • Provider name and NPI
  • Urgency level (standard vs. expedited)
  • Total page count
  • Contact number for questions

Source: Aetna Provider Relations

CVS Specialty Pharmacy Enrollment

Six-Step Enrollment Process

CVS Specialty handles Gattex dispensing for most Aetna plans. The enrollment process requires:

Step 1: Patient Demographics Complete name, DOB, address, contact preferences, and last four digits of SSN.

Step 2: Insurance Verification Gather medical and prescription insurance details, including RX BIN and PCN numbers.

Step 3: Clinical Information Document SBS diagnosis with ICD-10 codes, allergies, height, weight, and concomitant medications.

Step 4: Site of Care Coordination Specify injection training needs and administration location (home, clinic, or facility).

Step 5: Prescription Details Include strength, quantity, and refills as prescribed.

Step 6: Prescriber Authorization Signed authorization (no stamp signatures) allowing CVS Specialty to submit PA requests.

Enrollment Contacts

Source: CVS Specialty Enrollment Forms

Support Lines and Case Management

Member Services

  • Aetna Member Services: 1-800-279-1878 (TTY: 711)
  • Hours: Monday-Friday, 8 AM to 6 PM
  • What to ask: Coverage verification, formulary status, appeal deadlines

Provider Relations

  • Provider Line: 1-800-279-1878 (TTY: 711)
  • Specialty Drug Support: 1-866-814-5506 (TTY: 711)
  • Case Management: Available for complex cases requiring coordination

CVS Specialty Patient Support

  • General Support: 1-800-237-2767
  • Clinical Support: Injection training, side effect management
  • Financial Assistance: Copay program enrollment

When calling, have ready:

  • Member/patient ID number
  • Policy/group number
  • Prescriber information
  • Specific questions about coverage or appeals

Virginia External Review Process

If Aetna denies your internal appeal, Virginia offers independent external review through the State Corporation Commission Bureau of Insurance.

Eligibility and Timeline

You can request external review within 120 days of receiving a final denial from Aetna. The review is free and conducted by independent medical experts.

Required Documentation

Submit Form 216-A with:

  • Final denial letter from Aetna
  • Signed medical records release
  • Copy of insurance card
  • Medical records supporting treatment necessity
  • Any new information not included in internal appeals

Review Timelines

  • Standard review: 45 days
  • Expedited review: 72 hours (requires Form 216-C from your doctor)

Contact Information

Virginia SCC Consumer Services: 1-877-310-6560
Email: Submit forms via email address on Form 216-A
Success rate: External reviews nationally overturn 40-50% of denials

Source: Virginia External Review Process

Appeals Playbook for Aetna CVS Health

Level 1: Internal Appeal (First Level)

Timeline: 180 days from denial to file
Decision time: 30-45 days (standard), 72 hours (expedited)
How to file:

  • Online: Aetna member portal
  • Fax: 1-866-669-2459
  • Phone: 1-800-279-1878

Level 2: Internal Appeal (Second Level)

Timeline: 60 days from first-level denial
Decision time: 30 days
Requirements: Include new clinical information or peer-reviewed studies

Level 3: Virginia External Review

Timeline: 120 days from final internal denial
Decision time: 45 days (standard), 72 hours (expedited)
How to file: Form 216-A to Virginia SCC Bureau of Insurance

Note: Virginia allows expedited external review for cancer treatments without exhausting internal appeals first.

When Counterforce Health helps patients navigate these appeals, we focus on identifying the specific denial basis—whether it's PA criteria, step therapy, or "not medically necessary"—and crafting targeted rebuttals using the payer's own policy language. This systematic approach significantly improves approval rates for complex specialty medications like Gattex.

Common Denial Reasons and Fixes

Denial Reason Fix Strategy Required Documentation
No documented PN dependency Submit detailed PN logs Volume/frequency records ≥12 months
Inadequate baseline documentation Provide comprehensive history Specialist consultation notes
Failed to optimize enteral nutrition Document prior attempts Nutrition therapy records, failures
Quantity over limits Request exception Clinical justification for dosing
Non-formulary status File formulary exception Medical necessity, no alternatives
Step therapy not met Document contraindications Prior therapy failures/intolerance

Script for Peer-to-Peer Review

If your doctor requests a peer-to-peer review with Aetna's medical director:

"I'm requesting a peer-to-peer review for [patient name], member ID [number], regarding denial of Gattex for short bowel syndrome. The patient meets all FDA labeling criteria with documented PN dependency exceeding 12 months. I have baseline volume logs and can provide additional clinical rationale during the review."

FAQ: Gattex Coverage in Virginia

How long does Aetna CVS Health prior authorization take in Virginia?
Standard PA decisions are made within 30-45 days. Expedited reviews (for urgent medical situations) are completed within 72 hours.

What if Gattex is non-formulary on my plan?
You can request a formulary exception by submitting medical necessity documentation showing no covered alternatives are appropriate for your condition.

Can I request an expedited appeal in Virginia?
Yes, if your doctor certifies that delaying treatment would seriously jeopardize your health. Use Form 216-C for Virginia external review expedited requests.

Does step therapy apply if I've tried therapies outside Virginia?
Yes, documented prior therapy failures from any state count toward step therapy requirements. Include complete medical records in your PA submission.

How much does Gattex cost with Aetna CVS Health?
Costs vary by plan tier. A 30-vial kit has a wholesale cost around $46,893. Contact member services at 1-800-279-1878 to verify your specific copay or coinsurance.

What happens if my appeal is denied?
After exhausting Aetna's internal appeals, you can file for Virginia external review within 120 days. The independent review decision is binding on Aetna.

From our advocates: We've seen patients succeed by submitting comprehensive PN logs showing exact volumes and frequencies over 12+ months, rather than general statements about dependency. The more specific your documentation, the stronger your case becomes. This attention to detail often makes the difference between approval and denial.

For patients navigating complex specialty drug approvals, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and payer policies to identify specific coverage gaps and draft point-by-point rebuttals aligned with each plan's requirements.

Sources & Further Reading

Disclaimer: This guide provides educational information about insurance coverage processes and should not be considered medical advice. Coverage decisions depend on individual plan benefits and medical circumstances. Always consult with your healthcare provider about treatment options and work with your insurance plan directly for coverage determinations. For additional help with insurance appeals in Virginia, contact the State Corporation Commission Consumer Services at 1-877-310-6560.

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