By Counterforce Health Team in Taltz (ixekizumab) —

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

Aetna CVS Health requires prior authorization (PA) for Taltz (ixekizumab) in New Jersey, including step therapy with TNF inhibitor failure documentation, TB screening within 6 months, and specialist prescription. Submit the Taltz precertification form via fax (1-844-268-7263) or provider portal. If denied, you have 180 days for internal appeals, then 4 months for binding external review through New Jersey's IHCAP program administered by Maximus.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization PA required for all Taltz prescriptions Aetna precertification list Aetna 2025 PA List
Step Therapy Must fail TNF inhibitor first PA form section 4 Taltz PA form
Specialty Tier Tier 4-5 with higher copays Member formulary Plan documents
TB Screening Test within 6 months PA form clinical section PA requirements
Specialist Required Dermatologist or rheumatologist PA form prescriber section Medical policy
Appeal Deadline 180 days internal, then 4 months external NJ IHCAP guidelines NJ Department of Banking

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Requirements

Who: Patient or clinic staff
Action: Log into Aetna member portal or call member services to confirm Taltz is on formulary
Timeline: Same day
Documents needed: Member ID card, policy number

2. Gather Required Clinical Documentation

Who: Healthcare provider
Action: Compile diagnosis codes (L40.0 for plaque psoriasis, L40.50 for psoriatic arthritis), severity measures (BSA >10%, PASI ≥10), and TNF inhibitor failure records
Timeline: 1-3 days
Documents needed: Chart notes, lab results, photos, prior medication records

3. Complete TB Screening

Who: Healthcare provider
Action: Order PPD, IGRA, or chest X-ray if not done within 6 months
Timeline: 2-7 days for results
Documents needed: Negative TB test results dated within 6 months

4. Submit Prior Authorization Request

Who: Healthcare provider or staff
Action: Complete Taltz precertification form and fax to 1-844-268-7263
Timeline: Same day submission
Documents needed: Completed PA form, clinical notes, lab results, insurance card copy

5. Track Decision and Follow Up

Who: Provider or patient
Action: Check Aetna provider portal or call specialty pharmacy at 1-800-237-2767
Timeline: 30-45 days standard, 72 hours expedited
Next steps: If approved, proceed to specialty pharmacy; if denied, prepare appeal

Required Forms and Documentation

Primary Form

The Taltz Precertification Request Form is the main document required. Complete all sections legibly:

  • Patient Information: Demographics, member ID, prescriber NPI
  • Clinical Information: Diagnosis codes, severity documentation, treatment history
  • Prior Therapy: Detailed TNF inhibitor trials with doses, durations, and failure reasons
  • Safety Screening: TB test results, hepatitis screening if applicable

Required Attachments

  • Chart notes from last 3 months showing disease severity and treatment response
  • Laboratory results including TB screening
  • Photos documenting skin involvement (for psoriasis)
  • Prior authorization denials from other medications
  • Copy of insurance card

Submission Methods

  • Preferred: Fax to 1-844-268-7263
  • Alternative: Aetna provider portal (verify current URL with plan)
  • Northern NJ providers: May use EviCore portal for precertification
Clinician Corner: When documenting TNF inhibitor failure, include specific details: drug name, dose, frequency, duration of trial (minimum 3 months), objective measures of inadequate response (e.g., "adalimumab 40mg weekly x 12 weeks: PASI improved from 18 to 12, failed to achieve PASI75"), and any adverse effects or contraindications.

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
Insufficient severity documentation Provide objective measures BSA >10%, PASI ≥10, joint counts, photos with dates
Step therapy not met Detail TNF inhibitor failures Drug names, doses, durations ≥3 months, specific failure reasons
Missing TB screening Submit recent test results PPD, IGRA, or chest X-ray within 6 months
"Not medically necessary" Cite FDA approval and guidelines FDA labeling, AAD/ACR guidelines, peer-reviewed studies
Quantity limits exceeded Justify dosing regimen Weight-based calculations, FDA-approved dosing schedule

Sample Appeal Language

"Patient has moderate-to-severe plaque psoriasis (BSA 15%, PASI 16) with documented failure of adalimumab 40mg weekly for 16 weeks (PASI improvement <50%). Taltz is FDA-approved for this indication and recommended by AAD guidelines for TNF-experienced patients. TB screening negative on [date]."

Appeals Process in New Jersey

Internal Appeals with Aetna CVS Health

  1. Level 1: Submit written appeal within 180 days of denial
  2. Level 2: If Level 1 denied, automatic second review
  3. Timeline: Standard appeals decided within 30-45 days; expedited within 72 hours
  4. Contact: Member services or number on ID card

External Review Through NJ IHCAP

After exhausting internal appeals, New Jersey residents can request binding external review through the Independent Health Care Appeals Program (IHCAP), administered by Maximus.

Eligibility:

  • Completed both levels of internal appeals
  • Denial based on medical necessity, experimental/investigational status, or inappropriate limitations
  • Filed within 4 months of final internal denial

Process:

  1. Submit appeal via Maximus portal or fax 1-585-425-5296 for expedited cases
  2. Preliminary review within 5 business days
  3. Full review and binding decision within 45 days (48 hours if expedited)

Required Documents:

  • Member ID card copies
  • All denial letters from internal appeals
  • Medical records authorization forms
  • Clinical documentation supporting medical necessity
Note: External review decisions are binding on Aetna CVS Health. If approved, they must provide coverage as directed by the independent reviewers.

Specialty Pharmacy Setup

Once Taltz is approved, it must be dispensed through a specialty pharmacy, typically CVS Specialty.

CVS Specialty Contact Information

  • Phone: 1-800-237-2767 (TTY: 711)
  • Fax: 1-800-323-2445
  • Hours: 24/7 for urgent needs, standard hours for routine questions

Onboarding Process

  1. CVS Specialty will contact patient within 24-48 hours of PA approval
  2. Complete intake assessment including delivery preferences
  3. Schedule injection training if needed
  4. Arrange first shipment with temperature-controlled delivery

Services Included

  • Free overnight shipping
  • Injection training and support
  • Side effect monitoring
  • Refill reminders and coordination

Support Contacts and Resources

Aetna CVS Health Member Services

  • General member services: Number on your ID card
  • Specialty pharmacy: 1-800-237-2767
  • Pharmacy management: 1-800-238-6279 (TTY: 711)
  • Prior authorization status: 1-866-814-5506

New Jersey State Resources

  • NJ Department of Banking and Insurance: 1-800-446-7467
  • IHCAP hotline: 1-888-393-1062
  • Consumer complaints: File online or call main number

Manufacturer Support

  • Eli Lilly Taltz support: Check manufacturer website for current patient assistance programs
  • Copay assistance: May be available for commercially insured patients

At Counterforce Health, we help patients and clinicians navigate complex prior authorization requirements by analyzing denial letters, identifying specific coverage criteria, and drafting targeted appeals with evidence-based rebuttals. Our platform streamlines the process of getting specialty medications like Taltz approved by turning insurance obstacles into successful coverage outcomes.

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take for Taltz in New Jersey? Standard PA decisions typically take 30-45 days. Expedited reviews for urgent medical needs are completed within 72 hours. Track your request through the Aetna provider portal or by calling specialty pharmacy services.

What if Taltz is not on my Aetna formulary? You can request a formulary exception by demonstrating medical necessity and failure of preferred alternatives. Submit the same clinical documentation required for PA, emphasizing why formulary options are inappropriate.

Can I appeal if I've tried TNF inhibitors outside of New Jersey? Yes, document all prior treatments regardless of where they occurred. Include medical records, prescription history, and detailed failure documentation from previous providers.

Does step therapy apply if I have contraindications to TNF inhibitors? No, if you have documented contraindications (e.g., heart failure, active infections, TB risk), step therapy requirements may be waived. Provide clinical documentation of contraindications.

How much will Taltz cost with Aetna CVS Health coverage? Costs vary by plan but typically fall under specialty tier (Tier 4-5) with copays ranging from $50-$150 per month or coinsurance of 25-50%. Check your specific plan documents or call member services.

What happens if my external appeal is denied? NJ IHCAP decisions are binding and final for most cases. However, you may have options through federal appeals processes if you have Medicare Advantage or other federal coverage components.

Can my doctor submit appeals on my behalf? Yes, healthcare providers can submit both internal and external appeals with proper patient authorization. Many providers prefer to handle appeals directly due to their familiarity with clinical requirements.

How often do external appeals succeed in New Jersey? While specific statistics for NJ IHCAP aren't published, national data shows external appeals succeed approximately 40-50% of the time, particularly for specialty medications with strong clinical evidence.

This guide is for informational purposes only and does not constitute medical or legal advice. Coverage policies and appeal processes may change. Always verify current requirements with your insurance plan and consult healthcare providers for medical decisions. For additional consumer assistance in New Jersey, contact the Department of Banking and Insurance at 1-800-446-7467.

Sources & Further Reading

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.