By Counterforce Health Team in Lutathera (lutetium Lu-177 dotatate) —

How to Get Lutathera (Lutetium Lu-177 Dotatate) Covered by Aetna CVS Health in Washington: Complete Prior Authorization Guide

Answer Box: Getting Lutathera Covered by Aetna CVS Health in Washington

Lutathera (lutetium Lu-177 dotatate) requires prior authorization from Aetna CVS Health. The fastest path to approval: 1) Verify your plan's formulary status and PA requirements through the Aetna member portal, 2) Submit a complete PA request with somatostatin receptor-positive imaging, prior treatment failures, and medical necessity documentation, 3) If denied, file an internal appeal within 180 days, then request external review through Washington's Independent Review Organization (IRO) system. Start today by calling Aetna member services to confirm your exact plan type and downloading the current PA forms.

Table of Contents

  1. Verify Your Plan and Find Forms
  2. Prior Authorization Requirements
  3. Submission Portals and Process
  4. Medical Necessity Documentation
  5. Common Denial Reasons and Solutions
  6. Appeals Process in Washington
  7. CVS Specialty Pharmacy Setup
  8. Cost Assistance Programs
  9. When to Contact Washington Regulators
  10. Frequently Asked Questions

Verify Your Plan and Find Forms

Before starting your Lutathera prior authorization, confirm your exact Aetna plan type and access the current forms:

Step 1: Identify Your Plan Type

  • Commercial plans: Log into the Aetna member portal to view your Summary of Benefits
  • Medicare Advantage: Check if you have Aetna Medicare Part D coverage
  • Medicaid (Apple Health): Verify if your Washington Apple Health is managed by Aetna Better Health

Step 2: Download Current Forms

Aetna updates their precertification lists annually. Lutathera typically requires:

  • Prior authorization request form
  • Medical necessity documentation
  • Clinical notes and imaging reports
Note: Forms and requirements can change quarterly. Always verify you're using the most current version from Aetna's provider portal.

Prior Authorization Requirements

Coverage at a Glance

Requirement Details Documentation Needed
Diagnosis Somatostatin receptor-positive GEP-NETs (adults & pediatric ≥12) Pathology report, ICD-10 codes
Imaging Proof SSTR-positive confirmation Ga-68 DOTATATE PET/CT or Octreoscan
Prior Treatments Step therapy may apply Documentation of SSA trials, outcomes
Administration Qualified facility only Site of care verification
Dosing 7.4 GBq (200 mCi) IV every 8 weeks × 4 Treatment plan, amino acid protocol

Key Clinical Criteria

Based on Aetna's medical policies, Lutathera approval typically requires:

  1. Confirmed somatostatin receptor-positive GEP-NET
  2. Appropriate disease stage (metastatic or unresectable)
  3. Prior somatostatin analog management documented
  4. Adequate organ function (kidney, bone marrow, liver)
  5. Qualified treatment facility with radiation safety protocols

Submission Portals and Process

Electronic Submission (Preferred)

  • Aetna Provider Portal: Submit PA requests online with document upload capability
  • CVS Caremark Portal: For specialty pharmacy coordination
  • Fax Option: Check your denial letter or call member services for current fax numbers (verify with source linked below)

Required Supporting Documents

Upload these with your PA request:

  • Complete medical history and physical exam
  • Pathology reports confirming NET diagnosis
  • Somatostatin receptor imaging (DOTATATE PET or Octreoscan)
  • Prior treatment records (SSA therapy, outcomes)
  • Laboratory values (creatinine, CBC, liver function)
  • Treatment facility qualification documentation
Tip: Submit all documents simultaneously to avoid delays. Incomplete submissions are a common cause of initial denials.

Medical Necessity Documentation

Clinician Corner: Medical Necessity Letter Checklist

Your prescribing physician should include:

Patient-Specific Factors:

  • Confirmed histologic diagnosis of well-differentiated NET
  • Primary tumor site (gastroenteropancreatic)
  • Grade and staging information
  • SSTR expression level (if quantified)

Treatment History:

  • Prior somatostatin analog therapy (octreotide, lanreotide)
  • Duration, doses, and clinical response
  • Biochemical markers (chromogranin A, 5-HIAA trends)
  • Imaging progression documentation

Clinical Rationale:

  • Why Lutathera is appropriate now
  • Goals of treatment (symptom control, disease stabilization)
  • Alternative treatment considerations
  • Expected monitoring plan

Guideline Support: Reference established guidelines such as:

Common Denial Reasons and Solutions

Denial Reason Solution Strategy
Missing SSTR imaging Submit Ga-68 DOTATATE PET/CT or Octreoscan report showing positive uptake
Inadequate prior therapy Document SSA treatment duration, doses, and progression/symptoms
Facility qualifications Provide radiation safety certification and qualified staff credentials
"Experimental/investigational" Submit FDA approval letter and NCCN guideline inclusion
Non-formulary status Request formulary exception with clinical justification

Step Therapy Override Documentation

If Aetna requires step therapy, document:

  • Previous somatostatin analog trials with specific agents, doses, duration
  • Clinical outcomes or progression despite adequate therapy
  • Contraindications or intolerance to preferred agents
  • Urgency of treatment initiation

Appeals Process in Washington

Washington residents have strong appeal rights through state law (RCW 48.43.535). Here's your roadmap:

Internal Appeals (Required First Step)

Timeline: File within 180 days of denial Process: Submit written appeal to Aetna with additional clinical documentation Decision: Standard appeals decided within 30-45 days; expedited within 72 hours for urgent cases

External Review (Independent Review Organization)

If internal appeals fail, Washington law provides access to independent external review:

Who Qualifies: Any enrollee disputing denials for medical necessity, experimental/investigational determinations, or coverage disputes

Process:

  1. Request external review through Aetna (must complete internal appeals first)
  2. Aetna assigns case to certified IRO within 3 business days
  3. You get at least 5 business days to submit additional information to IRO
  4. IRO decision within 20 days (standard) or 72 hours (expedited)

Binding Decision: IRO decisions are binding on Aetna and must be implemented promptly

Washington State Support

Office of the Insurance Commissioner Consumer Hotline: 1-800-562-6900 Online Resources: Insurance.wa.gov appeals guidance

The OIC can help determine if your plan is subject to state external review rules and provide assistance throughout the process.

CVS Specialty Pharmacy Setup

Lutathera is administered in qualified medical facilities, not dispensed through retail pharmacy. However, CVS Specialty may coordinate:

Coordination Steps

  1. Enrollment: Your clinic will work with CVS Specialty for benefit verification
  2. Prior Authorization: CVS Specialty often handles PA submission on behalf of the facility
  3. Scheduling: Coordinate with nuclear medicine department for treatment timing
  4. Billing: Lutathera is billed using HCPCS code A9513 (per mCi)

Contact CVS Specialty directly for facility enrollment and coordination.

Cost Assistance Programs

Novartis Patient Assistance

  • Novartis Oncology Patient Assistance Program: May provide free medication for qualifying uninsured/underinsured patients
  • Co-pay Support: Check with Novartis for commercial insurance co-pay assistance programs

Washington State Resources

  • Apple Health (Medicaid): Expanded coverage in Washington may cover Lutathera for eligible patients
  • Washington State Prescription Drug Program: Additional state assistance programs

Foundation Support

  • Patient Advocate Foundation: Provides case management and financial assistance for cancer patients
  • CancerCare: Offers financial assistance grants for treatment-related costs

When to Contact Washington Regulators

Contact the Washington Office of the Insurance Commissioner if:

  • Aetna fails to provide timely appeal decisions
  • You're denied access to external review
  • You believe Aetna isn't following Washington state insurance laws
  • You need help understanding your appeal rights

Contact: 1-800-562-6900 or file a complaint at insurance.wa.gov

Frequently Asked Questions

Q: How long does Aetna CVS Health prior authorization take in Washington? A: Standard PA decisions are typically made within 15-30 business days. Expedited reviews for urgent cases must be completed within 72 hours.

Q: What if Lutathera is non-formulary on my plan? A: Request a formulary exception with medical necessity documentation. Include evidence that formulary alternatives are inappropriate or have failed.

Q: Can I request an expedited appeal? A: Yes, if waiting for the standard timeline could seriously jeopardize your health. Your physician must provide supporting documentation of urgency.

Q: Does step therapy apply if I've tried treatments outside Washington? A: Prior treatment history from any location should count toward step therapy requirements. Provide complete documentation of all prior therapies.

Q: What happens if my external review is denied? A: IRO decisions are typically final, but you can contact the Washington OIC for guidance on any remaining options or file complaints about the process.

Q: How much does Lutathera cost without insurance? A: Lutathera is billed per mCi using HCPCS A9513. Costs vary by facility but can be substantial. Pursue all coverage options before considering self-pay.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals through evidence-backed, payer-specific strategies. Our platform analyzes denial letters and plan policies to draft targeted rebuttals that align with each plan's specific requirements, improving approval rates and reducing administrative burden.

For complex prior authorization cases like Lutathera, having expert support can make the difference between approval and denial. Counterforce Health specializes in translating clinical evidence into the precise documentation format that payers require, helping ensure patients get access to life-saving treatments.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice or a guarantee of coverage. Always consult with your healthcare provider about treatment decisions and verify current insurance requirements with your specific plan. For personalized assistance with appeals, contact the Washington Office of the Insurance Commissioner at 1-800-562-6900.

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