By Counterforce Health Team in Taltz (ixekizumab) —

How to Get Taltz (Ixekizumab) Covered by Aetna CVS Health in Georgia: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Taltz Covered by Aetna CVS Health in Georgia

Taltz (ixekizumab) requires prior authorization from Aetna CVS Health in Georgia, with step therapy requirements for most plans. Your fastest path to approval: (1) Have your dermatologist or rheumatologist submit a PA through the Aetna provider portal with documentation of diagnosis, prior treatment failures, and TB screening, (2) If denied, file an internal appeal within 180 days, then (3) Request Georgia's external review within 60 days if needed. Start by calling Aetna member services at the number on your insurance card to confirm your specific formulary tier and PA requirements.

Table of Contents

  1. Coverage Basics: Is Taltz Covered?
  2. Prior Authorization Process
  3. Step Therapy Requirements
  4. Timing and Deadlines
  5. Common Denial Reasons and Solutions
  6. Appeals Process in Georgia
  7. Costs and Savings Options
  8. Specialty Pharmacy Requirements
  9. Frequently Asked Questions
  10. When to Escalate

Coverage Basics: Is Taltz Covered?

Taltz (ixekizumab) is included on Aetna's 2025 Specialty Drug List for approved indications including moderate-to-severe plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, and non-radiographic axial spondyloarthritis.

Coverage at a Glance

Requirement What It Means Where to Verify
Prior Authorization Required for all plans Aetna member portal
Formulary Tier Specialty tier (varies by plan) Your Summary of Benefits and Coverage
Step Therapy Must try preferred alternatives first Plan-specific drug guide
Quantity Limits 1 syringe per 28 days, 8 per 84 days Aetna policy 1739-H
Specialty Pharmacy CVS Specialty required Automatic with approval
Age Limits 6+ years for pediatric psoriasis FDA labeling

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Confirm Coverage (Patient)
    • Log into your Aetna member portal and search for "Taltz"
    • Note your formulary tier and any PA/step therapy flags
    • Timeline: 5-10 minutes
  2. Gather Clinical Documentation (Provider)
    • Diagnosis with ICD-10 codes
    • Disease severity measures (PASI, BSA, joint counts)
    • Prior treatment history and failures/intolerances
    • TB screening results (within 6 months)
    • Timeline: 15-30 minutes
  3. Submit PA Request (Provider)
    • Use Aetna provider portal or fax to 1-877-269-9916
    • Include all required documentation
    • Timeline: Same day submission
  4. Track Status (Patient/Provider)
    • Check portal for updates
    • Expect decision within 30-45 business days
    • Call member services for status updates
  5. Receive Decision
    • If approved: Prescription forwarded to CVS Specialty
    • If denied: Review denial letter and prepare appeal

Clinician Corner: Medical Necessity Letter Checklist

Your medical necessity letter should include:

  • Specific diagnosis with ICD-10 codes (e.g., L40.0 for psoriasis vulgaris)
  • Disease severity documentation: PASI score, BSA percentage, DLQI score, or joint counts
  • Prior treatments tried: Include medications, doses, duration, and specific reasons for failure or intolerance
  • Clinical rationale: Why Taltz is appropriate based on FDA labeling and professional guidelines
  • Safety screening: TB test results, infection history, vaccination status
  • Treatment goals: Expected outcomes and monitoring plan

Step Therapy Requirements

Most Aetna CVS Health plans require step therapy for Taltz, meaning you must try and fail preferred alternatives first. Requirements vary by indication:

For Psoriasis:

  • Trial of topical treatments (unless contraindicated)
  • At least one systemic therapy (methotrexate, cyclosporine) or phototherapy
  • May require trial of preferred TNF inhibitor (adalimumab, etanercept)

For Psoriatic Arthritis/Ankylosing Spondylitis:

  • Trial of at least one conventional DMARD (typically methotrexate)
  • May require trial of preferred TNF inhibitor before IL-17 agents

Step Therapy Exceptions:

  • Medical contraindications to preferred agents
  • Previous treatment failures documented in medical records
  • Severe disease requiring immediate advanced therapy
Tip: Document specific reasons for each treatment failure, including adverse effects, lack of efficacy, or contraindications. General statements like "patient can't take methotrexate" are often insufficient.

Timing and Deadlines

Standard Timeline:

  • PA submission to decision: 30-45 business days
  • Internal appeal deadline: 180 days from denial notice
  • Internal appeal decision: 30-45 days
  • Georgia external review deadline: 60 days from final internal denial
  • External review decision: 30-45 days

Expedited Options:

  • Expedited internal appeal: 72 hours for urgent situations
  • Expedited external review: 72 hours with physician documentation of urgency

Common Denial Reasons and Solutions

Denial Reason How to Overturn
Step therapy not met Document failures/contraindications to preferred agents with dates and specific reasons
Insufficient severity documentation Provide PASI scores, BSA percentages, photographs, functional impact measures
Missing TB screening Submit negative TB test results within 6 months
Non-formulary status Request formulary exception with medical necessity justification
Quantity limits exceeded Submit post-limit quantity exception with clinical rationale

Research shows that 67-75% of appeals are successful when proper documentation is provided, with success rates up to 89% for well-documented cases.

Appeals Process in Georgia

Internal Appeals with Aetna CVS Health

  1. File Within 180 Days
    • Use Aetna appeals form or write a formal letter
    • Include all supporting documentation
    • Mark "Expedited" if delay could harm your health
  2. Request Peer-to-Peer Review
    • Ask your provider to speak directly with Aetna's medical director
    • Often more effective than written appeals alone
  3. Track Your Appeal
    • Expect acknowledgment within 5 business days
    • Decision within 30-45 days (72 hours if expedited)

Georgia External Review Process

If your internal appeal is denied, Georgia law provides an independent external review through the Georgia Office of Commissioner of Insurance.

Key Requirements:

  • Must file within 60 days of Aetna's final internal denial
  • Submit request to Georgia OCI Administrative Procedure Division
  • No filing fee for consumers
  • Decision is binding on Aetna

How to Request:

  1. Download external review form from oci.georgia.gov or email [email protected]
  2. Include denial letters, medical records, and physician support letter
  3. Submit to Georgia OCI within 60-day deadline
  4. Independent Review Organization (IRO) assigned randomly
  5. Decision issued within 30-45 days (72 hours if expedited)
Note: Georgia's external review applies to fully insured plans. Self-insured employer plans may follow federal external review processes instead.

Costs and Savings Options

Insurance Coverage:

  • Taltz is typically on specialty tier with coinsurance (often 20-50% of cost)
  • Costs count toward your annual out-of-pocket maximum
  • Check your Summary of Benefits for specific specialty drug cost-sharing

Manufacturer Support:

  • Taltz Together Savings Program: May reduce copay to $5/month for eligible commercially insured patients
  • Lilly Cares Foundation: Free medication for uninsured/underinsured patients
  • Patient assistance through 1-844-TALTZ-NOW

Additional Resources:

  • Georgia 211: Call 2-1-1 for local assistance programs
  • Patient advocate organizations for your specific condition

Specialty Pharmacy Requirements

Once approved, Taltz must be dispensed through CVS Specialty Pharmacy for Aetna CVS Health plans:

  • Automatic transfer from your local pharmacy
  • 30-day supplies with home delivery
  • Injection training and support services included
  • Copay assistance processing available

Contact CVS Specialty at the number provided in your approval letter for scheduling and coordination.

Frequently Asked Questions

How long does Aetna CVS Health PA take in Georgia? Standard decisions take 30-45 business days. Expedited reviews are completed within 72 hours if your physician documents that delay could harm your health.

What if Taltz is non-formulary on my plan? You can request a formulary exception by providing medical necessity documentation showing why formulary alternatives are inappropriate for your condition.

Can I request an expedited appeal? Yes, if delay in treatment could seriously jeopardize your health or cause severe pain. Your physician must provide a supporting letter documenting the urgency.

Does step therapy apply if I failed treatments in another state? Yes, documented treatment failures from other states count toward step therapy requirements. Ensure your medical records are transferred to your Georgia provider.

What happens if I miss the 60-day external review deadline? Georgia's deadline is strict. Contact the Georgia OCI immediately to discuss options, though extensions are rare and typically only granted for extraordinary circumstances.

How much will Taltz cost with Aetna CVS Health? Costs vary by plan but expect specialty tier cost-sharing (often 20-50% coinsurance). The manufacturer's copay card may reduce this to $5/month for eligible patients.

When to Escalate

Contact the Georgia Office of Commissioner of Insurance at 404-656-2070 if:

  • Aetna doesn't respond within required timeframes
  • You need help with the external review process
  • You believe Aetna violated Georgia insurance laws

For additional consumer assistance, contact Georgians for a Healthy Future or Georgia Legal Services Program for complex cases.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to create point-by-point rebuttals with the right clinical evidence and citations, helping achieve higher approval rates for specialty medications like Taltz.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan and medical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For official appeals assistance in Georgia, contact the Georgia Office of Commissioner of Insurance.

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