By Counterforce Health Team in Taltz (ixekizumab) —

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

Answer Box: Getting Taltz Covered by Aetna CVS Health in New York

Aetna CVS Health requires prior authorization for Taltz (ixekizumab) with step therapy requirements, TB screening, and specialist prescription. The fastest path: (1) Complete the Taltz precertification form with documented moderate-to-severe psoriasis (BSA >3% or PASI score), prior therapy failures, and negative TB test within 6 months; (2) Submit via fax (1-877-269-9916) or Aetna provider portal; (3) If denied, file internal appeal within 180 days, then New York external appeal within 4 months for binding review.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria for Approval
  4. Coding Requirements
  5. Documentation Packet
  6. Submission Process
  7. CVS Specialty Pharmacy Transfer
  8. After Submission: Tracking Your Request
  9. Appeals Process in New York
  10. Common Denial Reasons & Solutions
  11. Cost Savings Options
  12. FAQ

Who Should Use This Guide

This guide is for New York patients with moderate-to-severe plaque psoriasis, psoriatic arthritis, or ankylosing spondylitis whose doctors have prescribed Taltz (ixekizumab) through Aetna CVS Health plans. You'll also find this helpful if you've already been denied and need to understand your appeal rights in New York.

Expected outcome: With proper documentation, most Taltz requests get approved within 30-45 days. If denied initially, New York's robust external appeal system gives you strong rights to overturn coverage denials through independent medical review.

Member & Plan Basics

Verify Your Coverage

Before starting, confirm your Aetna plan details:

  • Log into the Aetna member portal with your member ID
  • Search "Taltz" in the formulary tool to check tier status and requirements
  • Note your deductible and specialty tier copay

Plan Types That Cover Taltz

  • Commercial Aetna plans: Require prior authorization with step therapy
  • Aetna Better Health (Medicaid): Similar PA requirements with potential aid continuing during appeals
  • Medicare Advantage: May have different formulary placement
Note: Self-insured employer plans may have modified policies. Check with your HR department if requirements seem different.

Clinical Criteria for Approval

FDA-Approved Indications

Aetna covers Taltz for these conditions when criteria are met:

  • Moderate-to-severe plaque psoriasis (adults and children ≥6 years)
  • Active psoriatic arthritis
  • Ankylosing spondylitis
  • Non-radiographic axial spondyloarthritis

Severity Requirements

Condition Severity Threshold Documentation Needed
Plaque Psoriasis BSA >3% OR PASI ≥10 OR severe functional impact Photos, PASI score, quality of life assessment
Psoriatic Arthritis Active joint inflammation Joint counts, imaging, inflammatory markers
Ankylosing Spondylitis Active disease with objective findings BASDAI score, imaging, inflammatory markers

Step Therapy Requirements

Most patients must try and fail:

  1. Topical therapies (for psoriasis): corticosteroids, vitamin D analogs
  2. Phototherapy (if appropriate): PUVA, UVB
  3. Conventional systemics: methotrexate, cyclosporine, or acitretin
  4. Preferred biologics (plan-specific): may include TNF inhibitors
Important: Document specific reasons for discontinuation (lack of efficacy, intolerance, contraindications) with dates and dosages tried.

Coding Requirements

Essential ICD-10 Codes

  • L40.0 - Psoriasis vulgaris (plaque psoriasis)
  • L40.50 - Arthropathic psoriasis, unspecified
  • M45.9 - Ankylosing spondylitis, unspecified

HCPCS Billing Code

  • J1745 - Injection, ixekizumab, 1 mg
  • Typical billing: 80 units for maintenance dose (80 mg every 4 weeks)

Specialist Requirements

Prescriptions must come from:

  • Dermatologist (for psoriasis)
  • Rheumatologist (for arthritis/spondylitis)

Documentation Packet

Medical Necessity Letter Components

Your doctor's letter should include:

  1. Patient Information
    • Full name, DOB, Aetna member ID
    • Primary diagnosis with ICD-10 code
    • Date of diagnosis
  2. Disease Severity Documentation
    • BSA percentage or PASI score for psoriasis
    • Joint counts and functional assessments for arthritis
    • Objective measures (photos, imaging results)
  3. Prior Treatment History
    • Complete list of failed therapies with:
      • Drug names and doses
      • Duration of treatment
      • Specific reason for discontinuation
      • Dates of treatment periods
  4. Safety Screening
    • Negative TB test results (within 6 months)
    • Hepatitis B/C screening
    • Complete blood count
  5. Treatment Plan
    • Proposed Taltz dosing schedule
    • Monitoring plan
    • Expected outcomes

Required Attachments

  • Recent clinic notes (last 3 months)
  • Laboratory results
  • Photos of affected areas (for psoriasis)
  • Prior authorization denial letters (if resubmitting)
  • Insurance card copy
From our advocates: "The most successful appeals we see include before-and-after photos for psoriasis cases and detailed documentation of how each prior therapy was tried at optimal doses for adequate duration. Vague statements like 'patient failed methotrexate' often lead to denials, while specific details like 'patient discontinued methotrexate 20mg weekly after 16 weeks due to persistent nausea despite anti-emetics' typically result in approvals."

Submission Process

Step-by-Step Submission

  1. Download the correct form: Taltz Precertification Request
  2. Complete all required sections:
    • Patient demographics
    • Prescriber information with NPI
    • Diagnosis codes
    • Prior therapy documentation
    • Clinical justification
  3. Submit via preferred method:
    • Fax: 1-877-269-9916 (precertification)
    • Online: Aetna provider portal
    • Mail: Address on form
  4. Confirm receipt: Note confirmation number and submission date

Timeline Expectations

  • Standard review: 30-45 business days
  • Expedited review: 72 hours (for urgent medical needs)
  • Incomplete submissions: May receive requests for additional information

CVS Specialty Pharmacy Transfer

Once approved, Aetna automatically routes Taltz prescriptions to CVS Specialty Pharmacy.

Enrollment Process

  1. Provider completes: CVS Specialty Dermatology form
  2. Fax to: 1-800-323-2445
  3. Patient receives: Welcome call to schedule first shipment
  4. Delivery: 30-day supplies with injection training

Contact Information

  • CVS Specialty: 1-800-237-2767
  • Patient portal: Available after enrollment
  • Clinical support: Included with dispensing

After Submission: Tracking Your Request

Monitor Status

  • Aetna provider portal: Real-time status updates
  • Phone: Call number on your insurance card
  • Documentation: Keep all confirmation numbers and correspondence

What to Record

  • Submission date and method
  • Confirmation number
  • Representative names (if calling)
  • Any additional information requested
  • Decision date and outcome

Appeals Process in New York

Internal Appeals with Aetna

If your initial request is denied:

  1. File within: 180 days of denial letter
  2. Submit to: Same fax/portal as original request
  3. Include:
    • Original denial letter
    • Additional medical evidence
    • Updated physician letter addressing denial reasons
  4. Timeline: 30 days for standard review, 72 hours for expedited

New York External Appeals

New York provides strong patient protection through the Department of Financial Services external appeal process.

Eligibility

  • Aetna denied treatment as "not medically necessary"
  • Experimental/investigational determination
  • Out-of-network coverage disputes

Filing Process

  1. Complete internal appeal first (or request waiver)
  2. File within: 4 months of final Aetna denial
  3. Submit forms: DFS External Appeal
  4. Required documents:
    • Comprehensive Physician Attestation Form
    • Original denial letters
    • Medical records
    • Supporting literature

Timeline and Costs

  • Standard decision: 30 days
  • Expedited decision: 72 hours (24 hours for urgent drug denials)
  • Cost: $25 fee (waived for Medicaid/hardship)
  • Outcome: Binding decision on insurer

Additional New York Resources

  • Community Health Advocates: 888-614-5400 (free counseling)
  • Consumer Assistance Program: Available through DFS
  • Medicaid Fair Hearing: Alternative to external appeal for Medicaid plans

Counterforce Health specializes in helping patients navigate complex prior authorization and appeals processes. Our platform analyzes denial letters and creates targeted, evidence-backed appeals that address specific payer criteria, potentially saving weeks of back-and-forth with insurance companies.

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
Insufficient severity documentation Submit PASI scores, BSA measurements, photos Objective severity measures with dates
Step therapy not met Document specific failures with doses/durations Detailed prior therapy timeline
Missing TB screening Provide recent negative results TB test within 6 months of request
Not medically necessary Submit guidelines supporting use AAD/ACR treatment recommendations
Experimental/investigational Emphasize FDA-approved indication FDA labeling for specific condition

Cost Savings Options

Manufacturer Support

  • Taltz Together: 1-844-TALTZ-NOW
  • Copay assistance: Up to $25,000 annually for eligible patients
  • Free drug program: Available through Lilly Cares for uninsured

Additional Resources

  • Patient Access Network Foundation: Grants for specialty medications
  • HealthWell Foundation: Copay assistance programs
  • New York State programs: Check eligibility for additional coverage

FAQ

How long does Aetna CVS Health prior authorization take for Taltz in New York? Standard reviews take 30-45 business days. Expedited reviews for urgent medical needs are completed within 72 hours.

What if Taltz is not on my Aetna formulary? You can request a formulary exception with medical justification. This follows the same prior authorization process but requires stronger clinical rationale.

Can I get expedited approval if I'm currently on Taltz? Yes, if stopping treatment would cause significant health deterioration. Your doctor must document the urgent medical need in the request.

Does New York step therapy apply if I failed treatments in another state? Yes, documented failures from other states count toward step therapy requirements. Include complete medical records from previous providers.

What happens if the external appeal is denied? For Medicaid plans, you can request a state Fair Hearing. For commercial plans, the external appeal decision is typically final, though you may have federal appeal rights in some cases.

How much will Taltz cost with Aetna coverage? Costs vary by plan. Specialty tier copays typically range from $40-60 for generic-tier plans to several hundred dollars for high-deductible plans. Manufacturer copay cards can significantly reduce out-of-pocket costs.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements may vary by specific plan and can change. Always verify current requirements with your insurance provider and consult with your healthcare provider for medical decisions. For personalized assistance with complex prior authorization and appeals processes, Counterforce Health offers specialized support to help patients and providers navigate insurance coverage challenges more effectively.

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