By Counterforce Health Team in Tagrisso (osimertinib) —

How to Get Tagrisso (Osimertinib) Covered by Aetna in Georgia: PA Requirements, Appeals & Scripts

Answer Box: Getting Tagrisso Covered by Aetna in Georgia

Aetna requires prior authorization for Tagrisso (osimertinib) with documented EGFR mutation testing. Submit PA request through CVS Caremark Specialty Pharmacy (1-866-814-5506) with EGFR test results, diagnosis codes, and clinical notes. If denied, you have 180 days to file an internal appeal, then 60 days for Georgia DOI external review. First step today: call Aetna member services to confirm your formulary tier and PA requirements.

Table of Contents

  1. Plan Types & Coverage Implications
  2. Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. Specialty Pharmacy Requirements
  5. Cost-Share Basics
  6. Submission Process
  7. Common Approval Patterns
  8. Appeals Process in Georgia
  9. Where to Verify Coverage
  10. FAQ

Plan Types & Coverage Implications

Aetna offers multiple plan types in Georgia, each with different implications for Tagrisso coverage:

  • HMO Plans: Require referrals to oncology specialists; all specialty drugs must go through designated providers
  • PPO/EPO Plans: Allow direct access to oncologists; broader network for specialty pharmacy services
  • Medicare Plans: Follow CMS guidelines with additional Aetna restrictions
  • Medicaid (Georgia Families): Limited formulary with stricter step therapy requirements
Note: Regardless of plan type, Tagrisso requires prior authorization and specialty pharmacy dispensing through CVS Caremark.

Formulary Status & Tier Placement

Tagrisso is placed on Tier 4 (Specialty drugs) in most 2025 Aetna formularies, requiring specialty pharmacy use and higher cost-sharing. The drug is covered for FDA-approved indications but subject to utilization controls.

Coverage Requirements at a Glance

Requirement Details Source
Prior Authorization Required for all indications Aetna PA List
EGFR Testing FDA-approved test required Aetna Clinical Policy
Specialty Pharmacy CVS Caremark only Aetna Specialty Drug List
Step Therapy May require erlotinib/gefitinib first Aetna Drug Guide

Prior Authorization Requirements

Aetna covers Tagrisso only for specific, well-documented indications with required EGFR mutation testing.

Approved Indications

Medically necessary for:

  • First-line metastatic NSCLC with EGFR exon 19 deletions or exon 21 L858R mutations
  • Combination therapy with pemetrexed and platinum chemotherapy for locally advanced/metastatic NSCLC
  • Metastatic EGFR T790M mutation-positive NSCLC after TKI progression
  • Adjuvant therapy after tumor resection with EGFR mutations

Required Documentation

  1. EGFR Mutation Test Results (FDA-approved test)
  2. Pathology Report confirming NSCLC diagnosis
  3. Clinical Notes detailing treatment history
  4. ICD-10 Codes for lung cancer diagnosis
  5. Prior Therapy Documentation (if applicable)
Clinician Corner: Medical necessity letters should include specific EGFR mutation type, prior treatment failures/intolerances, contraindications to alternatives, and treatment goals aligned with FDA labeling.

Specialty Pharmacy Requirements

All Tagrisso prescriptions must be filled through CVS Caremark Specialty Pharmacy. Patients cannot use retail pharmacies or non-preferred specialty providers.

Setup Process

  1. Provider submits PA to CVS Caremark Specialty
  2. Patient enrollment in specialty pharmacy program
  3. Insurance verification and benefit determination
  4. Shipment coordination (typically 7-10 days)

CVS Caremark Specialty Contact:

  • Phone: 1-866-814-5506 (TTY: 711)
  • Fax: 1-866-249-6155

Cost-Share Basics

Tier 4 specialty drugs like Tagrisso typically have the highest cost-sharing under Aetna plans. Patients may face:

  • Deductible: Must be met before coverage begins
  • Coinsurance: Usually 25-40% of drug cost for specialty tiers
  • Out-of-Pocket Maximum: Annual limit on patient costs
Savings Options: AstraZeneca offers patient assistance through AZ&Me Prescription Savings Program for eligible patients.

Submission Process

Step-by-Step: Fastest Path to Approval

  1. Confirm EGFR Testing (Clinic): Ensure FDA-approved test results are available
  2. Submit PA Request (Clinic): Call 1-866-814-5506 or submit via provider portal
  3. Provide Documentation (Clinic): Include all required clinical evidence
  4. Patient Enrollment (Patient): Complete CVS Caremark specialty pharmacy setup
  5. Follow Up (Both): Track PA status and respond to requests for additional information
  6. Appeal if Denied (Both): File internal appeal within 180 days
  7. External Review (Patient): Request Georgia DOI review within 60 days if internal appeal fails

Timeline: Standard PA decisions typically take 30-45 business days; expedited reviews available for urgent cases (≤72 hours).

Common Approval Patterns

Strong submissions typically include:

  • Clear EGFR mutation documentation with specific mutation type
  • Treatment history showing appropriate sequencing
  • Contraindication evidence if step therapy bypass needed
  • Specialist consultation notes from oncology
  • Staging information confirming metastatic or adjuvant indication

Common Denial Reasons & Fixes

Denial Reason How to Overturn
No EGFR mutation documented Submit FDA-approved test results
Wrong indication/setting Clarify adjuvant vs. metastatic use per FDA label
Step therapy required Document erlotinib/gefitinib failure or contraindication
Medical necessity not established Provide oncologist attestation with clinical rationale

Appeals Process in Georgia

Georgia provides robust consumer protections for insurance denials through internal appeals and external review.

Internal Appeal Process

  • Deadline: 180 days from denial date
  • Decision Timeline: 45 business days (standard), 72 hours (expedited)
  • Submission: Aetna provider portal or member services

External Review (Georgia DOI)

After internal appeal denial, Georgia residents can request external review:

  • Deadline: 60 days from final internal denial
  • Process: Independent physician review
  • Timeline: 30 business days (standard), 72 hours (expedited)
  • Cost: Free to consumer
  • Contact: Georgia Department of Insurance, 1-800-656-2298
Important: Georgia's external review decision is binding on Aetna and required by state law.

Counterforce Health helps patients and clinicians navigate complex prior authorization and appeals processes by analyzing denial letters and crafting evidence-backed appeals that align with payer policies and clinical guidelines.

When to Escalate

Contact Georgia DOI Consumer Services if:

  • Aetna fails to meet decision deadlines
  • Required forms are not provided
  • Appeals process seems unfair or incomplete

Georgia DOI Consumer Services: 1-800-656-2298

Where to Verify Coverage

Always confirm current requirements through official sources:

  1. Aetna Member Portal: Log in to check formulary status
  2. Member Services: Call number on insurance card
  3. Provider Portal: Verify PA requirements and submission process
  4. CVS Caremark: Confirm specialty pharmacy requirements

Key verification points:

  • Current formulary tier placement
  • PA requirements for your specific plan
  • Step therapy obligations
  • Quantity limits or other restrictions

FAQ

How long does Aetna PA take in Georgia? Standard decisions take 30-45 business days. Expedited reviews for urgent cases are completed within 72 hours.

What if Tagrisso is non-formulary on my plan? Request a formulary exception with clinical documentation showing medical necessity and lack of suitable alternatives.

Can I request an expedited appeal? Yes, if your health condition poses serious risk with treatment delays. Both internal appeals and external reviews can be expedited.

Does step therapy apply if I failed other TKIs outside Georgia? Yes, but document prior failures/intolerances from any location. Aetna considers treatment history regardless of where it occurred.

What happens if I miss appeal deadlines? You may lose appeal rights. However, if you have good cause for delay (hospitalization, etc.), contact Aetna or Georgia DOI immediately.

Can my doctor handle the appeals process? Yes, with signed authorization. Many oncology practices have staff experienced with Aetna appeals processes.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies change frequently—always verify current requirements with Aetna and consult healthcare providers for medical decisions. For personalized assistance with complex prior authorization and appeals processes, Counterforce Health provides specialized support to help patients and clinicians navigate insurance coverage challenges.

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