By Counterforce Health Team in Hetlioz (tasimelteon) —

How to Get Hetlioz (tasimelteon) Covered by Aetna CVS Health in California: Complete Guide to Forms, Appeals, and PA Requirements

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

Hetlioz (tasimelteon) requires prior authorization from Aetna CVS Health and is dispensed through specialty pharmacy only. Key requirements include confirmed diagnosis (Non-24 or Smith-Magenis syndrome), specialist attestation, and documented failure of melatonin therapy. Submit PA requests via provider portal or fax to 1-888-267-3277. If denied, California patients have strong appeal rights through internal review and Independent Medical Review (IMR). First step today: Verify your plan covers specialty drugs and gather sleep logs, diagnosis documentation, and prior treatment records.

Table of Contents

  1. Start Here: Verify Your Plan and Find the Right Forms
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Online Tools
  4. Fax Numbers and Mailing Addresses
  5. CVS Specialty Pharmacy Enrollment
  6. Support Lines and Contact Numbers
  7. California Appeals and Independent Medical Review
  8. Common Denial Reasons and How to Fix Them
  9. Costs and Patient Assistance Programs
  10. FAQ: Hetlioz Coverage with Aetna CVS Health

Start Here: Verify Your Plan and Find the Right Forms

Before starting your Hetlioz prior authorization, confirm these basics:

Plan Verification Checklist:

  • Log into your Aetna member portal to verify specialty drug coverage
  • Check if your plan includes CVS Caremark prescription benefits
  • Confirm your plan is regulated by California's DMHC (most HMOs and managed care plans)
  • Note your member ID, group number, and current formulary year

Key Policy Information:

  • Hetlioz is non-formulary on most Aetna plans, requiring prior authorization
  • Both Hetlioz capsules and Hetlioz LQ suspension require PA
  • Quantity limits apply: typically 30 capsules per 30 days for 20mg strength
  • Authorization duration: usually 12 months with renewal requirements
Note: California law requires Aetna to process standard PA requests within 5 business days and urgent requests within 72 hours.

Prior Authorization Forms and Requirements

Required Documentation

For Non-24-Hour Sleep-Wake Disorder:

  • Confirmed diagnosis with ICD-10 code G47.24
  • Documentation of total blindness (no light perception in both eyes)
  • Sleep specialist, neurologist, or psychiatrist attestation
  • Sleep logs showing circadian rhythm disruption (minimum 14 days)
  • Evidence of failed melatonin trial (minimum 30 days, preferably 6 months)
  • Exclusion of other primary sleep disorders

For Smith-Magenis Syndrome:

  • Clinical diagnosis of SMS with ICD-10 code Q93.88
  • Genetic confirmation when available
  • Documentation of nighttime sleep disturbances
  • Specialist attestation
  • Failed melatonin trial documentation
  • Evidence of sleep quality improvement goals

California-Specific PA Form

Use the California Prescription Drug Prior Authorization or Step Therapy Exception Request Form. This form includes California-specific requirements and timelines.

Form Completion Tips:

  • Mark "urgent" if treatment delay could worsen the patient's condition
  • Attach all clinical documentation as PDF files
  • Include complete prescriber information and DEA number
  • Specify exact Hetlioz formulation (capsules vs. LQ suspension)

Submission Portals and Online Tools

Primary Submission Methods

Availity Provider Portal (Recommended)

  • Electronic submission with real-time status tracking
  • Upload clinical documents directly
  • Automatic confirmation receipts
  • Faster processing than fax submissions

Aetna Provider Portal

  • Access through Aetna's provider resources
  • Submit PA requests and check authorization status
  • View formulary information and coverage policies

CoverMyMeds Platform

  • Third-party electronic PA system
  • Integrates with many EMR systems
  • Real-time benefit verification
Tip: Electronic submissions typically process faster than fax and provide confirmation receipts.

Fax Numbers and Mailing Addresses

Specialty Drug Submissions

Primary Fax: 1-888-267-3277 (specialty drugs including Hetlioz) Standard Drug Fax: 1-877-269-9916 (non-specialty medications)

Mailing Address for PA Requests: Aetna Pharmacy Management P.O. Box 6590 Scottsdale, AZ 85261

Cover Sheet Requirements:

  • Patient name and Aetna member ID
  • Prescriber name and NPI number
  • Drug name: Hetlioz (tasimelteon)
  • Mark "URGENT" if expedited review needed
  • Total number of pages being faxed

CVS Specialty Pharmacy Enrollment

Hetlioz must be dispensed through CVS Specialty Pharmacy or an approved specialty network pharmacy.

Enrollment Process

  1. Provider Initiates Enrollment
  2. Patient Information Needed
    • Aetna member ID card
    • Complete mailing address
    • Emergency contact information
    • Allergy and medication history
  3. Specialty Pharmacy Services
    • Medication counseling and education
    • Adherence monitoring and support
    • Coordination with healthcare providers
    • Home delivery with temperature control

CVS Specialty Contact Information:

Support Lines and Contact Numbers

For Patients

Aetna Member Services: 1-888-792-3862 (TTY: 711)

  • Check PA status and coverage details
  • Request expedited review for urgent cases
  • Get help with appeals and grievances

CVS Caremark: 1-800-CAREMARK (1-800-227-3627)

  • Prescription benefit questions
  • Formulary information
  • Step therapy exception requests

For Healthcare Providers

Aetna Provider Help: 1-800-238-6279 (1-800-AETNA-RX)

  • PA status inquiries
  • Clinical policy questions
  • Peer-to-peer review requests

Prior Authorization Status: Available through provider portals or by calling the provider help line with patient information ready.

California Appeals and Independent Medical Review

California offers robust appeal rights for specialty drug denials through a three-level process.

Level 1: Peer-to-Peer Review

  • Request within 14 days of initial denial
  • Direct discussion between prescriber and Aetna medical director
  • Prepare clinical rationale and treatment guidelines
  • Document outcomes for potential appeal use

Level 2: Internal Appeal with Aetna

  • Submit written appeal within 180 days of denial
  • Include updated clinical documentation
  • Request expedited review if urgent (72-hour decision)
  • Standard appeals decided within 30 days

Level 3: California Independent Medical Review (IMR)

When to Use IMR:

  • After exhausting Aetna's internal appeals
  • For denials based on "not medically necessary"
  • For experimental/investigational treatment disputes

IMR Process:

  • File through DMHC website or call 1-888-466-2219
  • Independent sleep medicine specialists review your case
  • No cost to patients
  • Standard decisions within 45 days, expedited within 7 days
  • Binding decision - if approved, Aetna must authorize within 5 days

IMR Success Rates: California data shows approximately 68% of specialty drug denials are overturned through IMR, particularly for well-documented cases with clear medical necessity.

From our advocates: We've seen patients successfully overturn Hetlioz denials at IMR by providing comprehensive sleep logs, genetic testing results for SMS patients, and detailed documentation of melatonin trial failures. The key is thorough documentation of the circadian rhythm disorder's impact on daily functioning and the specific reasons standard treatments didn't work.

Common Denial Reasons and How to Fix Them

Denial Reason Required Documentation to Overturn
"Diagnosis not confirmed" Submit ICD-10 codes, specialist evaluation, genetic testing (SMS), blindness documentation (Non-24)
"Step therapy not completed" Provide detailed melatonin trial records with doses, duration, and outcomes
"Not FDA-approved indication" Include current FDA labeling showing approved indications
"Quantity exceeds limits" Submit clinical rationale for dosing, body weight considerations, treatment response
"Experimental/investigational" Provide FDA approval documentation and clinical practice guidelines

Medical Necessity Letter Template

Your specialist should include these elements:

  • Patient's specific diagnosis and ICD-10 code
  • Detailed sleep disturbance symptoms and functional impact
  • Complete history of prior treatments and failures
  • Clinical rationale for Hetlioz specifically
  • Expected treatment outcomes and monitoring plan
  • References to FDA labeling and clinical guidelines

Costs and Patient Assistance Programs

Typical Costs

  • Hetlioz capsules: Approximately $5,895 for 30×20mg capsules
  • Hetlioz LQ: Often around $24,678 for common bottle sizes
  • Insurance coverage varies significantly by plan

Manufacturer Support Programs

HetliozSolutions Patient Support:

  • Copay assistance for eligible patients
  • Prior authorization support
  • Appeals assistance
  • Nurse educator support

Vanda Pharmaceuticals Programs:

  • Patient assistance for uninsured/underinsured
  • Free drug programs based on income eligibility
  • Clinical trial information

California-Specific Resources

  • Health Consumer Alliance: Free assistance with insurance appeals
  • Legal aid organizations: Help with complex coverage disputes
  • California Department of Insurance: Consumer assistance hotline 1-800-927-4357

FAQ: Hetlioz Coverage with Aetna CVS Health

How long does Aetna PA approval take in California? Standard requests: 5 business days maximum by California law. Urgent requests: 72 hours. If Aetna misses these deadlines, the request may be deemed approved.

What if Hetlioz is non-formulary on my plan? You can request a formulary exception with medical necessity documentation. If denied, appeal through internal review and potentially California IMR.

Can I get expedited review? Yes, if treatment delay could jeopardize your health. Mark requests as "urgent" and provide clinical justification for expedited processing.

Does step therapy apply if I tried melatonin outside California? Yes, document all prior treatments regardless of location. California's step therapy override laws may apply if you have contraindications to preferred alternatives.

What happens if CVS Specialty Pharmacy is out-of-network? Aetna typically covers specialty medications through their contracted specialty pharmacies. Verify network status and request exceptions if needed.

How often do I need to renew authorization? Typically annually. Start renewal process 30-60 days before expiration to avoid treatment interruptions.

Can I appeal multiple times? Yes, you can pursue internal appeals with new documentation and escalate to California IMR. Each level offers a fresh review of your case.

What if I move from another state to California? Transfer your care to a California specialist and ensure continuity documentation. California's consumer protections may provide additional appeal options.

Counterforce Health helps patients navigate complex prior authorization and appeal processes for specialty medications like Hetlioz. Our platform analyzes denial letters, identifies specific coverage criteria, and generates evidence-backed appeals tailored to your insurance plan's requirements. We work with patients, clinicians, and specialty pharmacies to turn coverage denials into successful approvals through targeted, data-driven advocacy. Visit counterforcehealth.org to learn more about our comprehensive coverage support services.

For additional assistance with Hetlioz coverage challenges, Counterforce Health provides specialized support for navigating Aetna's complex prior authorization requirements and California's appeals process.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about treatment decisions and work with your insurance plan directly for coverage determinations. Coverage policies and requirements may change. Verify current information with Aetna CVS Health and California regulators before making coverage decisions.

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