By Counterforce Health Team in Tagrisso (osimertinib) —

How to Get Tagrisso (Osimertinib) Covered by Aetna CVS Health in Michigan: Prior Authorization Forms, Appeals, and State Rights

Answer Box: Getting Tagrisso Covered by Aetna CVS Health in Michigan

Fastest path to approval: Submit prior authorization with documented EGFR mutation test results, specific NSCLC diagnosis/stage, and prescriber attestation that Tagrisso meets FDA labeling criteria. Aetna typically requires 30-45 days for standard decisions, 72 hours for urgent oncology cases. If denied, Michigan patients have 127 days to file external review with DIFS.

First step today: Contact your oncologist's office to verify they have your complete EGFR mutation report and request they submit the Aetna prior authorization form through their provider portal or CVS Specialty directly.

Table of Contents

  1. Why Michigan State Rules Matter
  2. Aetna CVS Health Tagrisso Requirements
  3. Prior Authorization Timeline Standards
  4. Step Therapy Protections and Medical Exceptions
  5. Continuity of Care Rights
  6. Michigan External Review Process
  7. Common Denial Reasons and Solutions
  8. Appeals Playbook: Internal to External Review
  9. Cost Assistance and Patient Support
  10. When to Contact Michigan Regulators
  11. FAQ

Why Michigan State Rules Matter

Michigan's insurance landscape offers strong patient protections that work alongside Aetna CVS Health's national policies. With Blue Cross Blue Shield of Michigan covering about 67% of commercial members, Aetna operates as a significant secondary player, serving roughly 15-20% of the commercial market plus Medicare Advantage and Medicaid managed care through Aetna Better Health of Michigan.

How state and plan policies interact: While Aetna sets its own clinical criteria for Tagrisso coverage—requiring documented EGFR mutations and appropriate cancer staging—Michigan law governs the procedural aspects: how quickly decisions must be made, what constitutes a valid appeal, and your right to independent external review.

Line-of-business differences: Commercial Aetna plans follow Michigan's Patient's Right to Independent Review Act, while Aetna Better Health (Medicaid) follows state Medicaid appeals processes. Medicare Advantage plans blend federal Medicare appeals rights with some state protections.

Aetna CVS Health Tagrisso Requirements

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Tagrisso prescriptions Aetna Precert List Aetna 2024
EGFR Mutation Must document specific sensitizing mutation FDA-approved test results Aetna Tagrisso Policy
Formulary Tier Specialty tier (high copay) Plan-specific drug guide CVS Specialty
Prescriber Oncology specialist required Board certification verification Aetna PA form
Quantity Limits 30-day supply standard Plan formulary Varies by plan

Essential Clinical Documentation

Aetna's approval hinges on five key elements:

  1. EGFR mutation confirmation: Exon 19 deletion, L858R point mutation, or T790M resistance mutation from an FDA-approved companion diagnostic
  2. Appropriate indication: First-line metastatic, adjuvant post-resection (stage IB-IIIA), or T790M-positive after prior EGFR TKI progression
  3. Disease staging: Pathology report confirming non-small cell lung cancer with TNM staging
  4. Performance status: ECOG 0-2 or equivalent functional assessment
  5. Prescriber qualification: Medical oncology, hematology-oncology, or pulmonary oncology specialist

Counterforce Health specializes in helping patients navigate exactly these documentation requirements, turning complex clinical criteria into targeted, evidence-backed prior authorization submissions that speak directly to each payer's specific approval standards.

Prior Authorization Timeline Standards

Michigan Regulatory Requirements

Standard decisions: 30 calendar days maximum from receipt of complete request Urgent/expedited decisions: 72 hours when delay would seriously jeopardize life or health Incomplete requests: 15 days to notify of missing information; clock restarts when received

Aetna-Specific Timelines

  • Commercial plans: Typically 30-45 business days for standard oncology PA
  • Medicare Advantage: 14 calendar days standard, 72 hours expedited
  • Aetna Better Health (Medicaid): 14 calendar days, with Michigan Medicaid appeal rights
Tip: Request expedited review if you're experiencing disease progression, symptomatic disease, or approaching a treatment window where delay could affect curative potential.

Step Therapy Protections and Medical Exceptions

Michigan law requires insurers to grant step therapy exceptions when:

  • Required drugs were previously tried and failed
  • Required drugs are contraindicated or likely to cause harm
  • Required drugs are not in the patient's best medical interest
  • Patient is stable on the requested non-preferred drug

Documentation for Step Therapy Override

Prior failure evidence:

  • Drug names, doses, duration of treatment
  • Objective measures of failure (imaging showing progression, labs, symptoms)
  • Specific adverse events requiring discontinuation
  • Dates of treatment and discontinuation

Medical necessity rationale:

  • Why Tagrisso is appropriate for this patient's specific EGFR mutation
  • Alignment with NCCN guidelines for the patient's disease stage and line of therapy
  • Contraindications to preferred alternatives (drug interactions, organ dysfunction, prior toxicities)

Continuity of Care Rights

If you're already stable on Tagrisso when switching to an Aetna plan, Michigan law provides transition protections:

90-day bridge coverage: New plans must cover ongoing specialty medications for at least 90 days while PA is processed No gap in therapy: Coverage continues during the prior authorization review period Appeal protections: If PA is denied, coverage continues during the internal and external appeal process

Michigan External Review Process

When You Can File External Review

After receiving a final denial from Aetna's internal appeal process, Michigan patients have 127 days to request external review through the Department of Insurance and Financial Services (DIFS).

Standard vs. Expedited External Review

Standard review: 60 days maximum, often completed faster Expedited review: 72 hours when physician certifies that delay would seriously jeopardize life, health, or ability to regain maximum function

Required Documentation for Expedited Review

Your oncologist's letter must explicitly state:

  • "Delaying this treatment would seriously jeopardize the patient's life and/or substantially risk the loss of the patient's ability to regain maximum function"
  • Specific clinical rationale for urgency (disease progression, treatment window, symptomatic burden)
  • Why covered alternatives are inadequate for this patient's situation

How to file: DIFS External Review Request online, or call 877-999-6442

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
"No documented EGFR mutation" Submit complete lab report FDA-approved test with specific mutation identified
"Not FDA-approved indication" Clarify indication and staging Pathology report, staging studies, treatment history
"Step therapy not completed" Request medical exception Prior treatment failures, contraindications, or stability on current therapy
"Experimental/investigational" Reference FDA approval and guidelines FDA labeling, NCCN guidelines, peer-reviewed evidence
"Quantity exceeds limits" Justify dosing and duration Prescribing information, patient-specific factors, treatment plan

Appeals Playbook: Internal to External Review

Level 1: Internal Appeal (Required First Step)

Timeline: Must file within 180 days of denial Process: Submit through Aetna member portal or mail to address on denial letter Documents to include:

  • Original denial letter
  • Completed appeal form
  • Updated clinical documentation
  • Physician letter of medical necessity

Level 2: External Review (Michigan DIFS)

Timeline: 127 days after final internal denial Process: Online submission or paper form Decision: Binding on Aetna if overturned Cost: Free to patients

From our advocates: "We've seen Michigan external reviews consistently favor patients when the clinical documentation clearly demonstrates that Tagrisso meets FDA labeling criteria and the patient has an appropriate EGFR mutation. The key is ensuring your oncologist's letter directly addresses the specific reason for denial cited in Aetna's letter."

Cost Assistance and Patient Support

Manufacturer Support

  • AstraZeneca Access 360: Patient assistance program for eligible uninsured/underinsured patients
  • Tagrisso copay card: Up to $25,000 annual assistance for commercially insured patients
  • Contact: 1-844-275-2360 or AstraZeneca patient assistance

Foundation Grants

  • CancerCare Co-Payment Assistance Foundation
  • Patient Advocate Foundation Co-Pay Relief Program
  • Leukemia & Lymphoma Society Patient Financial Aid Program

When to Contact Michigan Regulators

Contact DIFS if:

  • Aetna fails to meet Michigan timeline requirements
  • You believe the denial violates state insurance law
  • You need help understanding your appeal rights
  • The external review process isn't proceeding appropriately

Michigan DIFS Consumer Hotline: 877-999-6442 Online complaint: DIFS complaint portal

Counterforce Health's platform can help identify when regulatory intervention might be appropriate by analyzing denial patterns and ensuring your appeal documentation meets both Aetna's clinical criteria and Michigan's procedural requirements.

FAQ

How long does Aetna CVS Health prior authorization take for Tagrisso in Michigan? Standard decisions take 30-45 days; expedited reviews for urgent oncology cases are completed within 72 hours when physician urgency is documented.

What if Tagrisso is non-formulary on my Aetna plan? Request a formulary exception with documentation of medical necessity, EGFR mutation status, and why formulary alternatives are inappropriate for your specific situation.

Can I request an expedited appeal if I'm experiencing disease progression? Yes. Have your oncologist document that delay would seriously jeopardize your health and submit both expedited internal appeal and, if needed, expedited external review through DIFS.

Does step therapy apply if I failed EGFR inhibitors outside Michigan? Prior treatment failures from other states count toward step therapy completion. Submit complete treatment records showing drug names, dates, and reasons for discontinuation.

What happens if DIFS external review overturns Aetna's denial? The decision is binding. Aetna must approve coverage and cannot appeal the external review decision. Coverage typically begins within days of the favorable decision.

How much does Tagrisso cost without insurance in Michigan? List price exceeds $15,000 per 30-day supply. Patient assistance programs and specialty pharmacies may offer significant discounts for eligible patients.

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan benefits and clinical circumstances. Always consult your healthcare provider and insurance plan directly for guidance specific to your situation.

Need help navigating your specific situation? Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific approval pathway for each case.

Sources & Further Reading

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