By Counterforce Health Team in Gilenya (fingolimod) —

How to Get Gilenya (Fingolimod) Covered by Aetna CVS Health in Georgia: Prior Authorization Forms and Appeals Guide

Quick Answer: Getting Gilenya Covered by Aetna CVS Health in Georgia

Gilenya (fingolimod) requires prior authorization from Aetna CVS Health and must meet specific medical necessity criteria. You'll need documentation of your relapsing MS diagnosis (ICD-10 code G35), baseline EKG, ophthalmic exam, and evidence of failed first-line treatments. Submit through your provider using the Availity portal or fax to specialty pharmacy services. If denied, you have 180 days for internal appeals and 60 days for external review through Georgia's Department of Insurance. Start by having your neurologist gather required clinical documentation and submit the PA request at least two weeks before your intended start date.

Table of Contents

What This Guide Covers

This guide helps patients with multiple sclerosis and their healthcare providers navigate Aetna CVS Health's prior authorization process for Gilenya (fingolimod) in Georgia. Whether you're dealing with an initial request, an appeal, or a renewal, you'll find step-by-step instructions, required forms, and state-specific deadlines.

Who this helps:

  • Patients diagnosed with relapsing forms of MS
  • Neurologists and clinic staff submitting PA requests
  • Anyone appealing an Aetna CVS Health denial in Georgia
  • Caregivers helping navigate the approval process

Before You Start: Verify Your Coverage

Check Your Plan Type and Network Status

First, confirm your specific Aetna plan details:

  • Commercial plans: Standard prior authorization applies
  • Medicare Advantage: May follow CMS coverage criteria
  • Medicaid plans: Different formulary may apply

Verify your neurologist is in-network with Aetna, as out-of-network providers face additional hurdles.

Confirm Gilenya's Formulary Status

Gilenya typically requires prior authorization on most Aetna plans and may be subject to step therapy requirements. Generic fingolimod options are often preferred over brand Gilenya. Check your specific plan's formulary through the Aetna member portal or call member services.

Gather Required Documentation

Medical Necessity Criteria

Aetna covers Gilenya for relapsing forms of multiple sclerosis when these criteria are met:

Requirement Details Documentation Needed
Diagnosis Relapsing MS or clinically isolated syndrome ICD-10 code G35, MRI findings, clinical notes
Age 10 years or older Date of birth verification
Prescriber Neurologist (directly or consultation) Provider credentials, specialty confirmation
Step Therapy Failed first-line DMTs Records of prior interferon beta or glatiramer acetate trials
Safety Monitoring Baseline assessments completed EKG, ophthalmic exam, vaccination status

Essential Clinical Documentation

Your neurologist must provide:

  • Confirmed diagnosis of relapsing MS with ICD-10 code G35
  • Documentation of prior disease-modifying therapy failures or contraindications
  • Baseline EKG results (required due to cardiac monitoring needs)
  • Recent ophthalmic examination report (to screen for macular edema)
  • Current vaccination status and any needed updates
  • Treatment goals and monitoring plan

For step therapy exceptions:

  • Specific DMTs tried, duration, and dates
  • Reason for discontinuation (lack of efficacy, intolerance, contraindications)
  • Clinical evidence supporting need for Gilenya specifically
Tip: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing your specific denial reason and crafting point-by-point rebuttals aligned to your plan's own rules. Their platform can help identify the exact clinical documentation needed for your Aetna appeal.

Submit Your Prior Authorization Request

Submission Methods

Primary options for providers:

  1. Availity provider portal (preferred method)
  2. Electronic Medical Record (EMR) integration
  3. Fax: Use Aetna's specialty pharmacy fax lines
  4. Phone: For urgent requests only

For specialty pharmacy enrollment: Use the CVS Specialty "Multiple Sclerosis Orals and Injectables Enrollment Form" and fax to 1-800-323-2445.

Step-by-Step Submission Process

1. Complete the prior authorization form

  • Use Aetna's MS-specific PA form
  • Include all required clinical information
  • Ensure prescriber's original signature (no stamps)

2. Attach supporting documentation

  • Baseline EKG and interpretation
  • Ophthalmic exam results
  • Prior therapy documentation
  • Current clinical notes

3. Submit at least 2 weeks early

  • Allow time for processing and any additional requests
  • Earlier submission prevents treatment delays

4. Request confirmation

  • Get submission confirmation number
  • Document submission date and method

Contact Information

  • Commercial plans: 1-888-632-3862 (TTY: 711)
  • Specialty Pharmacy: 1-866-814-5506 (TTY: 711)
  • CVS Specialty enrollment: 1-800-237-2767

Follow-Up and Tracking

When to Follow Up

  • Day 3: Confirm receipt of submission
  • Day 10: Check processing status
  • Day 20: Inquire about timeline if no decision
  • Day 30: Escalate if approaching deadline

What to Ask

"I'm calling about prior authorization request #[number] for Gilenya submitted on [date]. Can you provide the current status and expected decision timeline?"

Document all interactions with reference numbers, representative names, and next steps.

Typical Approval Timelines

Standard Processing Times

Request Type Aetna Timeline Georgia Requirements
Standard PA 30-45 days No state mandate for commercial
Expedited/Urgent 72 hours Available for urgent medical needs
Medicare Advantage 14 days standard, 72 hours expedited CMS requirements apply

Factors That Speed Approval

  • Complete documentation on first submission
  • Clear medical necessity justification
  • Proper ICD-10 coding
  • Neurologist as prescriber

Common Delays

  • Missing baseline testing results
  • Incomplete step therapy documentation
  • Wrong submission pathway
  • Provider credentialing issues

If You're Asked for More Information

Aetna may request additional clinical information to support medical necessity. Common requests include:

Clinical clarifications:

  • More detailed prior therapy history
  • Specific contraindication documentation
  • Updated disease activity assessment
  • Monitoring plan details

Respond promptly to avoid automatic denials. You typically have 14 days to provide requested information.

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason How to Address
Step therapy not met Document specific failures/contraindications to preferred DMTs
Missing baseline tests Submit EKG, ophthalmic exam, lab results
Not medically necessary Provide clinical evidence of disease activity and treatment goals
Non-formulary Request formulary exception with medical justification

First Steps After Denial

  1. Review the denial letter carefully for specific reasons
  2. Gather additional supporting evidence addressing each denial point
  3. File internal appeal within 180 days of denial notice
  4. Consider peer-to-peer review with Aetna's medical director

Appeals Process in Georgia

Internal Appeals

Timeline: File within 180 days of denial Process: Submit written appeal with additional documentation Decision time: 30 days for standard, 72 hours for expedited

External Review Through Georgia DOI

If your internal appeal is denied, Georgia law provides external review rights:

Key deadlines:

  • 60 days from internal appeal denial to request external review
  • Submit to Georgia Department of Insurance
  • Decision typically within 30 business days

Required documentation:

  • Copy of denial letters
  • Internal appeal results
  • Supporting medical records
  • Completed Georgia DOI external review form

Contact: Georgia Department of Insurance Consumer Services at 1-800-656-2298 or visit oci.ga.gov.

Note: External review decisions are binding on Aetna and free for consumers in Georgia.

Expedited Appeals

For urgent medical situations, request expedited appeals that bypass standard timelines. This applies when waiting could seriously jeopardize your health.

Renewal and Re-authorization

Gilenya authorizations typically last 12 months. Plan for renewal 30-60 days before expiration.

Renewal documentation:

  • Current clinical status
  • Evidence of treatment benefit or disease stability
  • Updated monitoring results
  • Continued medical necessity justification

From our advocates: We've seen many patients successfully maintain Gilenya coverage by documenting stability metrics like reduced relapse rates or stable MRI findings. Starting the renewal process early and maintaining detailed treatment logs throughout the year helps demonstrate ongoing medical necessity.

FAQ

Q: How long does Aetna prior authorization take in Georgia? A: Standard requests take 30-45 days, while expedited requests are processed within 72 hours for urgent medical needs.

Q: What if Gilenya is non-formulary on my plan? A: You can request a formulary exception by demonstrating medical necessity and providing evidence that preferred alternatives are inappropriate.

Q: Can I request an expedited appeal? A: Yes, if waiting for standard processing would seriously jeopardize your health. Both internal and external expedited appeals are available.

Q: Does step therapy apply if I've tried DMTs outside Georgia? A: Yes, prior therapy documentation from any location counts toward step therapy requirements, provided proper medical records are available.

Q: What's the difference between brand Gilenya and generic fingolimod for coverage? A: Generic fingolimod is typically preferred. Brand Gilenya requires additional documentation showing inability to use the generic formulation.

Q: Who can help me with the appeals process in Georgia? A: Georgia Department of Insurance Consumer Services (1-800-656-2298) provides free assistance with appeals and external reviews.

Quick Checklist

Before Starting

  • Confirm Aetna plan type and neurologist network status
  • Check Gilenya formulary tier and PA requirements
  • Schedule baseline EKG and ophthalmic exam

Documentation to Gather

  • MS diagnosis with ICD-10 code G35
  • Prior DMT trial history and outcomes
  • Baseline EKG results
  • Recent ophthalmic examination
  • Current vaccination status
  • Treatment goals and monitoring plan

Submission Process

  • Complete Aetna PA form with neurologist
  • Submit via Availity portal or approved fax
  • Request confirmation and reference number
  • Schedule follow-up calls

If Denied

  • Review denial letter for specific reasons
  • File internal appeal within 180 days
  • Consider peer-to-peer review
  • Prepare for external review if needed (60-day deadline)

Healthcare coverage decisions can feel overwhelming, but understanding your rights and the specific requirements helps you advocate effectively. Counterforce Health helps patients and providers navigate these complex processes by analyzing denial patterns and creating targeted appeals that address insurers' specific criteria.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements may change. Always verify current requirements with Aetna and consult with your healthcare provider about treatment decisions.

Sources & Further Reading

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.