How to Get Retevmo (selpercatinib) Covered by Aetna (CVS Health) in Michigan: Decision Tree, Forms & Appeals Guide
Answer Box: Quick Path to Retevmo Coverage
To get Retevmo (selpercatinib) covered by Aetna (CVS Health) in Michigan: First, confirm you have FDA-validated RET alteration testing via RNA-based NGS (like FoundationOne CDx). Submit prior authorization through your provider with complete medical records showing RET-positive cancer diagnosis, prior therapy failures if applicable, and safety monitoring plan. Aetna typically decides within 72 hours with complete documentation. If denied, you have 180 days for internal appeals, then 127 days for Michigan DIFS external review.
Start today: Ask your oncologist to order RET testing if not done, or request PA submission if testing is positive.
Table of Contents
- How to Use This Decision Tree
- Eligibility Triage: Do You Qualify?
- If Likely Eligible: Documentation Checklist
- If Possibly Eligible: Tests to Request
- If Not Yet Eligible: Alternatives & Exceptions
- If Denied: Michigan Appeals Pathway
- Coverage Requirements at a Glance
- Common Denial Reasons & Fixes
- Costs & Patient Assistance
- FAQ
How to Use This Decision Tree
This guide helps Michigan patients and their care teams navigate Aetna (CVS Health) coverage for Retevmo (selpercatinib). Start with the eligibility triage below, then follow the appropriate pathway. Each section includes specific forms, timelines, and contact information verified from official sources.
Note: Retevmo requires prior authorization from Aetna CVS Health for all plans. The medication costs approximately $23,000-$26,000 per month without coverage.
Eligibility Triage: Do You Qualify?
Answer these questions to determine your pathway:
✅ Likely Eligible
- Diagnosis confirmed: RET fusion-positive NSCLC, RET-mutant medullary thyroid cancer, or RET fusion-positive thyroid cancer
- Testing completed: FDA-validated RET alteration test (RNA-based NGS preferred)
- Safety cleared: Recent ECG, liver function tests, electrolytes within normal limits
- Prior therapy documented: If applicable for your cancer type
⚠️ Possibly Eligible
- Diagnosis suspected but RET testing incomplete or inconclusive
- Safety monitoring needs updating (ECG >3 months old, missing labs)
- Documentation gaps in prior therapy history
❌ Not Yet Eligible
- No RET alteration confirmed or testing method not FDA-validated
- Contraindications present: Uncontrolled hypertension, significant cardiac issues
- Required prior therapies not attempted (if step therapy applies)
If Likely Eligible: Documentation Checklist
Required Documents for Aetna PA Submission
Clinical Documentation:
- RET alteration test results from FDA-approved assay (FoundationOne CDx, FoundationOne Liquid CDx, or equivalent RNA-based NGS)
- Pathology report confirming cancer diagnosis with ICD-10 codes
- Recent imaging showing disease status
- Complete medication history and prior treatment failures (if applicable)
Safety Monitoring:
- ECG within 3 months showing baseline QTc
- Laboratory results: electrolytes, liver function, TSH
- Blood pressure readings (must be controlled)
- Current medication list (screen for QT-prolonging drugs)
Provider Documentation:
- Medical necessity letter addressing Aetna's criteria
- Treatment plan with monitoring schedule
- Prescriber attestation of appropriate use
Submission Process
Timeline: Submit through Aetna provider portal or fax to CVS Specialty at 1-866-249-6155. Standard decision within 72 hours of complete submission.
For Urgent Cases: Request expedited review if treatment delay would seriously jeopardize health. Include provider statement of medical urgency.
If Possibly Eligible: Tests to Request
RET Testing Requirements
Request RNA-based next-generation sequencing from your oncologist. FDA-approved options include:
- FoundationOne CDx (tissue-based)
- FoundationOne Liquid CDx (blood-based)
- Other validated NGS platforms with RET fusion detection
Tip: Liquid biopsy may be appropriate when tissue is limited, but sensitivity can be lower in low-burden disease.
Safety Assessments Needed
Before PA submission:
- ECG to establish baseline QTc interval
- Comprehensive metabolic panel (electrolytes, liver function)
- TSH level
- Blood pressure monitoring and control if elevated
Timeline to Re-apply: Once testing and safety assessments are complete, typically 2-4 weeks depending on lab turnaround.
If Not Yet Eligible: Alternatives & Exceptions
Alternative RET Inhibitors
- Gavreto (pralsetinib): Alternative selective RET inhibitor with similar indications
- Multikinase TKIs: For medullary thyroid cancer, cabozantinib or vandetanib may be options per guidelines
Formulary Exception Process
For non-formulary status or step therapy override:
- Provider submits exception request to Aetna CVS Health
- Include clinical justification for why preferred alternatives are inappropriate
- Document contraindications, adverse effects, or prior failures with preferred drugs
- Decision within 72 hours for standard requests, 24 hours for expedited
Submission: Fax to 1-866-249-6155 or submit via Aetna provider portal.
If Denied: Michigan Appeals Pathway
Level 1: Internal Appeal with Aetna
- Timeline: 180 days from denial date to file
- Process: Submit appeal through member services or provider portal
- Documentation: Include new clinical information, peer-reviewed literature, guideline support
- Decision: Within 30 days (expedited: 72 hours with urgency documentation)
Level 2: Peer-to-Peer Review
- When: If initial appeal denied
- Process: Provider requests discussion with Aetna medical director
- Preparation: Have clinical rationale, guidelines, and patient-specific factors ready
Level 3: Michigan External Review
- Timeline: 127 days from final Aetna denial to file with Michigan DIFS
- Forms: Health Care Request for External Review (verify current form)
- Process: Independent medical review by qualified specialists
- Decision: Within 60 days (expedited: 72 hours with provider urgency letter)
- Contact: Michigan DIFS at 877-999-6442
From our advocates: We've seen Michigan external reviews frequently overturn denials for FDA-approved targeted therapies when the clinical documentation clearly supports medical necessity and the insurer's criteria are met. The key is thorough preparation of the clinical record before submission.
Coverage Requirements at a Glance
| Requirement | Details | Source |
|---|---|---|
| Prior Authorization | Required for all plans | Aetna PA List |
| RET Testing | FDA-validated NGS required | FDA Companion Diagnostics |
| Safety Monitoring | ECG, labs, BP required | Retevmo Prescribing Info |
| Formulary Status | Varies by plan; exceptions available | Contact plan directly |
| Appeals Deadline | 180 days (Aetna), 127 days (Michigan DIFS) | Michigan DIFS |
Common Denial Reasons & Fixes
| Denial Reason | Solution | Required Documentation |
|---|---|---|
| "Not medically necessary" | Submit clinical evidence package | FDA indication, guidelines, treatment history |
| "Experimental/investigational" | Provide FDA approval documentation | FDA label, indication-specific evidence |
| Missing RET testing | Complete validated testing | RNA-based NGS results from approved lab |
| Safety concerns not addressed | Submit monitoring plan | ECG, labs, BP control documentation |
| Step therapy not completed | Request exception or complete steps | Prior therapy failures, contraindications |
| Non-formulary status | File formulary exception | Clinical superiority evidence, alternatives tried |
Costs & Patient Assistance
Manufacturer Support
Lilly Cares Foundation may provide assistance for eligible patients. Contact: 1-833-808-1234 or visit LillyCares.com (verify current program details).
Additional Resources
- State pharmaceutical assistance programs (verify Michigan-specific options)
- Cancer-specific foundations offering medication grants
- Hospital charity care programs for financial hardship cases
Counterforce Health helps patients and providers prepare targeted appeals by analyzing denial letters and crafting evidence-backed rebuttals aligned to payer-specific criteria. The platform streamlines the documentation process and tracks appeal deadlines to improve approval rates.
FAQ
How long does Aetna (CVS Health) prior authorization take in Michigan? Standard PA decisions are made within 72 hours of receiving complete documentation. Expedited requests for urgent cases are decided within 24 hours.
What if Retevmo is not on my Aetna formulary? You can request a formulary exception through your provider. Submit clinical justification showing why Retevmo is medically necessary and preferred alternatives are inappropriate.
Can I request an expedited appeal in Michigan? Yes, both Aetna internal appeals and Michigan DIFS external reviews offer expedited processes (72 hours) when treatment delay would seriously jeopardize your health. A provider letter documenting urgency is required.
Does step therapy apply to Retevmo? Step therapy requirements vary by plan. For RET-altered cancers, exceptions are often granted since Retevmo targets a specific molecular alteration not addressed by other therapies.
What happens if Michigan DIFS external review is denied? You may seek judicial review in Michigan circuit court within 60 days of the DIFS decision. Consult with a healthcare attorney for this process.
How much does Retevmo cost without insurance? Cash prices range from approximately $23,000-$26,000 per 30-day supply, depending on the strength prescribed.
Can liquid biopsy testing qualify for Retevmo coverage? Yes, FDA-approved liquid biopsy tests like FoundationOne Liquid CDx can detect RET alterations, though tissue-based testing may be preferred when available.
What safety monitoring is required during Retevmo treatment? Regular ECGs to monitor QT interval, liver function tests, electrolyte panels, blood pressure monitoring, and TSH levels are required per FDA labeling.
Sources & Further Reading
- Aetna Prior Authorization Lists
- Retevmo FDA Prescribing Information
- Michigan DIFS External Review Process
- FDA Companion Diagnostic List
- Lilly Patient Assistance Programs
Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan directly. For assistance with complex appeals, Counterforce Health provides specialized support in preparing evidence-backed coverage requests and appeals for prescription medications.
Last updated: January 2025. Verify current forms, timelines, and contact information with official sources.
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