By Counterforce Health Team in Retevmo (selpercatinib) —

How to Get Retevmo (Selpercatinib) Covered by Aetna in Washington: Prior Authorization Guide and Appeal Scripts

Answer Box: Getting Retevmo Covered by Aetna in Washington

Aetna requires prior authorization for Retevmo (selpercatinib), with documentation of RET fusion testing and step therapy compliance. Most approvals take 72 hours with complete documentation. If denied, you have 60 days to appeal internally, then can request external review through Washington's Independent Review Organization (IRO).

First steps today:

  1. Confirm RET fusion status with FDA-approved testing (FoundationOne CDx or Guardant360 CDx)
  2. Have your oncologist submit prior authorization via Aetna's provider portal with complete clinical records
  3. Use CVS Specialty Pharmacy for dispensing once approved

Table of Contents

Policy Overview

Aetna (CVS Health) classifies Retevmo as a specialty medication requiring prior authorization across all plan types—HMO, PPO, and Medicare Advantage. The drug is typically covered on specialty tiers with higher cost-sharing, ranging from $50-$500+ monthly depending on your specific plan.

Key policy elements:

  • Prior authorization mandatory before first fill
  • Specialty pharmacy distribution only (primarily CVS Specialty)
  • Step therapy requirements for most indications
  • Quantity limits may apply based on FDA dosing
  • Annual reauthorization typically required

You can find your specific coverage details in your Aetna formulary documents or by calling member services at 1-888-632-3862.

Medical Necessity Requirements

Aetna covers Retevmo for FDA-approved indications when medical necessity is established. The drug is approved for:

  • RET fusion-positive non-small cell lung cancer (NSCLC)
  • RET-mutant medullary thyroid cancer
  • RET fusion-positive thyroid cancer (adult and pediatric)

Coverage at a Glance

Requirement What It Means Documentation Needed Source
PA Required Must get approval before dispensing Complete PA form with clinical records Aetna PA List
RET Testing Confirmed RET alteration by validated test FoundationOne CDx or Guardant360 CDx results FDA Companion Diagnostics
Step Therapy Try preferred alternatives first Documentation of prior therapy failures/contraindications Aetna Clinical Policy
Specialty Pharmacy Must use network specialty pharmacy Prescription routed to CVS Specialty CVS Specialty
Quantity Limits Dosing per FDA label Prescriber attestation to appropriate dosing FDA Prescribing Information

Step Therapy and Exceptions

Most Aetna plans require step therapy before approving Retevmo, meaning you must try and fail preferred alternatives unless contraindicated.

Typical step therapy sequence:

  1. For RET+ NSCLC: May require trial of platinum-based chemotherapy or immunotherapy
  2. For medullary thyroid cancer: May require trial of cabozantinib or vandetanib
  3. Exceptions granted for: Medical contraindications, prior failures, or when Retevmo is first-line per current guidelines

Medical Exception Pathways

You can bypass step therapy by documenting:

  • Contraindications to required step therapies
  • Prior failures with adequate trials of step therapy drugs
  • Clinical urgency where delay would be detrimental
  • Updated guidelines supporting first-line Retevmo use
Tip: The 2024 NCCN guidelines support first-line Retevmo for RET+ NSCLC, which strengthens exception requests.

Required Diagnostics and Documentation

Aetna requires comprehensive documentation to establish medical necessity:

Essential Clinical Documentation

  • RET alteration confirmation via FDA-approved companion diagnostic
  • Histologic diagnosis with staging information
  • Prior treatment history including response and toxicity
  • Performance status and life expectancy assessment
  • Baseline labs including liver function, electrolytes, TSH
  • Baseline ECG to assess QT interval

Safety Monitoring Requirements

Given Retevmo's potential for QT prolongation and drug interactions, Aetna expects documentation of:

  • Medication reconciliation screening for QT-prolonging drugs
  • Electrolyte monitoring plan (calcium, magnesium, potassium)
  • ECG monitoring schedule during treatment
  • Management plan for acid-reducing medications

Specialty Pharmacy Requirements

Retevmo must be dispensed through an Aetna-contracted specialty pharmacy, primarily CVS Specialty Pharmacy. Prescriptions sent to retail pharmacies will be rejected.

Specialty pharmacy process:

  1. Prescriber submits PA request and prescription simultaneously
  2. CVS Specialty contacts patient for enrollment and delivery setup
  3. Prior authorization must be approved before first shipment
  4. Home delivery is standard; some locations offer pickup

Contact CVS Specialty: 1-800-237-2767

Evidence to Support Approval

Strong clinical evidence improves approval chances. Include these key references in your medical necessity letter:

FDA Approval Evidence

  • LIBRETTO-001 trial data supporting efficacy in RET+ cancers
  • FDA prescribing information confirming approved indications
  • Companion diagnostic validation for RET testing methods

Clinical Guidelines Support

  • NCCN Guidelines for NSCLC and thyroid cancer
  • ASCO/CAP biomarker testing guidelines
  • Specialty society recommendations from thoracic oncology and endocrine surgery groups
Clinician Corner: Structure your medical necessity letter with: (1) patient diagnosis and staging, (2) RET testing results with lab/date, (3) prior therapy history and outcomes, (4) clinical rationale for Retevmo, (5) safety monitoring plan, and (6) guideline citations supporting use.

Common Denial Reasons and Solutions

Denial Reason How to Overturn
"Missing RET testing" Submit FDA-approved companion diagnostic results (FoundationOne CDx or Guardant360 CDx)
"Step therapy not met" Document contraindications or failures with required prior therapies
"Not medically necessary" Provide peer-reviewed evidence, guidelines, and detailed clinical rationale
"Experimental/investigational" Cite FDA approval date and approved indications
"Wrong site of care" Confirm prescription routed to CVS Specialty or approved network pharmacy

Appeals Process in Washington

Washington provides strong consumer protections for insurance appeals, with specialist-to-specialist review requirements effective 2025.

Internal Appeals (Required First Step)

  • Timeline: 60 days from denial to file
  • Standard review: 30 days for decision
  • Expedited review: 72 hours for urgent cases
  • Submit to: Address/portal specified in denial letter

External Review (Independent Review Organization)

If internal appeals fail, Washington offers binding external review:

  • Timeline: 4 months from final internal denial to request
  • Specialist review: Oncologist must review oncology denials (2025 law)
  • Decision timeframe: 15 days (standard), 72 hours (urgent)
  • How to request: Washington Insurance Commissioner appeal form

Washington Insurance Commissioner: 1-800-562-6900

Patient Phone Script for Aetna Appeals

"I'm calling to appeal the denial of Retevmo for my RET-positive [cancer type]. The denial letter is dated [date] and my member ID is [number]. I have new clinical information supporting medical necessity and would like to request [standard/expedited] review. Can you please provide the appeal submission address and required forms?"

Cost Assistance Options

Even with insurance approval, Retevmo can be expensive. Several assistance programs are available:

Manufacturer Support

  • Lilly Cares Foundation: Income-based free drug program
  • Retevmo Savings Program: Copay assistance for commercially insured patients
  • Contact: 1-833-808-1234 or LillyCares.com

Additional Resources

  • CancerCare Co-Payment Assistance: Grants up to $10,000 annually
  • Patient Access Network (PAN): Disease-specific assistance funds
  • Washington State pharmaceutical assistance programs (verify eligibility with state)

From Our Advocates

We've seen many Washington patients successfully overturn initial Retevmo denials by ensuring their oncologist includes specific language about RET testing methodology and clearly documents why alternative treatments aren't appropriate. The key is comprehensive documentation upfront—appeals often succeed when the clinical picture is complete, but the process is much smoother when the initial PA request includes all necessary evidence.

FAQ

How long does Aetna prior authorization take for Retevmo in Washington? Standard PA decisions are made within 72 hours of complete submission. Expedited reviews (for urgent cases) are completed within 24 hours.

What if Retevmo is non-formulary on my Aetna plan? You can request a formulary exception with documentation that preferred alternatives are inappropriate or have failed. The process is similar to standard PA but may require additional clinical justification.

Can I request an expedited appeal if my cancer is progressing? Yes. Document the urgent medical need in your appeal request. Expedited appeals in Washington must be decided within 72 hours for urgent cases.

Does step therapy apply if I've already failed treatments outside Washington? Yes, prior treatment failures from any location count toward step therapy requirements. Provide complete treatment records and response documentation.

What happens if the external review upholds Aetna's denial? The external review decision is binding on Aetna. If upheld, you may consult legal counsel or explore alternative funding sources, but the appeals process is typically exhausted.

How do I find out if my Aetna plan covers Retevmo? Check your plan's formulary document or call member services at 1-888-632-3862. All Aetna plans require PA regardless of formulary status.

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex insurance approvals by turning denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements, pulling the right clinical evidence and meeting procedural deadlines. Learn more at www.counterforcehealth.org.

When facing a Retevmo denial, remember that Counterforce Health can help identify the specific denial basis and draft appeals that address Aetna's exact criteria while incorporating the clinical evidence that Washington's specialist reviewers expect to see.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Insurance coverage decisions depend on individual plan terms and clinical circumstances. Always consult your healthcare provider and insurance plan for guidance specific to your situation. For additional help with insurance appeals in Washington, contact the Office of the Insurance Commissioner at 1-800-562-6900.

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