By Counterforce Health Team in Tavneos (avacopan) —

How to Get Tavneos (Avacopan) Covered by Aetna CVS Health in Ohio: Complete 2025 Guide with Forms and Appeals

Quick Answer: Getting Tavneos Covered by Aetna CVS Health in Ohio

Yes, Aetna CVS Health covers Tavneos (avacopan) in Ohio with prior authorization. The fastest path: Your specialist must submit a PA request with documented GPA/MPA diagnosis (ICD-10: M31.31 or M31.7), ANCA-positive lab results, and evidence of standard therapy use. If denied, you have 180 days to appeal internally, then external review through Ohio's Independent Review Organization. Start today: Call Aetna at 1-855-364-0974 to confirm your plan's specific requirements and get the PA form.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping for ANCA Vasculitis
  3. Product Coding: NDC, HCPCS, and Units
  4. Clean Prior Authorization Request
  5. Common Coding Pitfalls
  6. Verification with Aetna Resources
  7. Appeals Process in Ohio
  8. Quick Audit Checklist
  9. FAQ

Coding Basics: Medical vs. Pharmacy Benefit

Tavneos (avacopan) is an oral specialty medication that's primarily covered under the pharmacy benefit, not medical. This distinction matters for billing and prior authorization.

Pharmacy Benefit Path (Most Common):

  • Billed using NDC number: 73129-0101-01 (10mg capsules, 180-count bottle)
  • Processed through CVS Caremark/CVS Specialty
  • Standard quantity limit: 180 capsules per 30 days
  • Prior authorization required through pharmacy benefit PA process

Medical Benefit Path (Rare):

  • Uses HCPCS J-code: J8499 ("Prescription drug, oral, non-chemotherapeutic, NOS")
  • Typically only for specific plan arrangements
  • Still requires prior authorization with clinical documentation
Tip: Always verify with Aetna which benefit covers Tavneos for your specific plan. Most commercial and Medicaid plans use pharmacy benefit processing.

ICD-10 Mapping for ANCA Vasculitis

Accurate diagnosis coding is critical for Tavneos approval. Use these specific ICD-10 codes:

Condition ICD-10 Code Documentation Requirements
Granulomatosis with polyangiitis (GPA) M31.31 ANCA serology (PR3 or c-ANCA), biopsy results
Microscopic polyangiitis (MPA) M31.7 ANCA serology (MPO or p-ANCA), clinical findings
ANCA-associated vasculitis (general) I77.82 Confirmed ANCA positivity, organ involvement

Key Documentation Words That Support Coding:

  • "Severe active ANCA-associated vasculitis"
  • "PR3-ANCA positive" or "MPO-ANCA positive"
  • "Renal involvement with proteinuria/hematuria"
  • "Pulmonary involvement with nodules/hemorrhage"
  • "Biopsy-confirmed necrotizing vasculitis"
Note: Avoid unspecified vasculitis codes (M31.9) as they often trigger denials. Always document ANCA status and specific subtype when possible.

Product Coding: NDC, HCPCS, and Units

NDC Information:

  • Primary NDC: 73129-0101-01 (Avacopan 10mg capsules, 180-count)
  • Billing unit: Each capsule (10mg)
  • Standard dose: 30mg (3 capsules) twice daily = 6 capsules/day

HCPCS/J-Code (if medical benefit):

  • J8499 - Prescription drug, oral, non-chemotherapeutic, NOS
  • Units calculation: Bill per day supply or per capsule (verify with Aetna)
  • Modifiers: Rarely needed for oral medications

Units Math for 30-Day Supply:

  • Daily dose: 6 capsules (30mg twice daily)
  • 30-day quantity: 180 capsules total
  • Day supply: 30 days
  • Never exceed 180 capsules per 30 days without prior authorization override

Clean Prior Authorization Request

Here's what a complete Tavneos PA request should include:

Required Clinical Documentation

1. Diagnosis Confirmation:

  • ICD-10 code (M31.31, M31.7, or I77.82)
  • ANCA serology results with titers
  • Biopsy report (if available)
  • Organ involvement documentation

2. Treatment History:

  • Previous therapies: glucocorticoids, cyclophosphamide, rituximab
  • Outcomes: failure, intolerance, contraindications
  • Current standard therapy plan (Tavneos is adjunctive only)

3. Prescriber Information:

  • Must be rheumatologist, nephrologist, or pulmonologist
  • DEA number and NPI
  • Specialty board certification

4. Monitoring Plan:

  • Baseline liver function tests
  • Planned monitoring schedule
  • Safety considerations

Submission Details

Common Coding Pitfalls

Avoid these frequent errors that trigger denials:

Pitfall Problem Solution
Wrong quantity Prescribing >180 caps/30 days Stick to 6 capsules daily maximum
Missing ANCA status Using unspecified vasculitis codes Document PR3 or MPO ANCA results
Non-specialist prescriber Primary care or other specialty Transfer to rheum/neph/pulm
Monotherapy indication Prescribing without standard therapy Document concurrent immunosuppression
Missing liver monitoring No baseline LFTs Include hepatic function assessment
From our advocates: We've seen many Tavneos approvals succeed after initial denials simply by adding the missing ANCA lab values and clarifying that the patient will continue standard therapy alongside Tavneos. Complete documentation makes all the difference.

Verification with Aetna Resources

Before submitting your PA request:

1. Check Current Formulary Status:

2. Verify Member Eligibility:

  • Active coverage on date of service
  • Specialty pharmacy benefits included
  • Prior authorization benefits available

3. Review Latest Policy:

Appeals Process in Ohio

If your Tavneos PA is denied, Ohio law provides strong appeal rights:

Internal Appeals with Aetna

Timeline: 180 days from denial date to submit Process:

  1. Use denial letter instructions to submit appeal
  2. Include additional clinical documentation
  3. Request peer-to-peer review if available
  4. Decision within 60 days (72 hours if expedited)

External Review (Independent Review Organization)

Timeline: 60 days after final internal denial Process:

  1. Submit request to: Aetna External Review Unit, PO Box 818000, Cleveland, OH 44181-8000
  2. Fax: (860) 975-1526 | Phone: (877) 848-5855
  3. IRO decision within 30 days (72 hours expedited)
  4. Decision is binding on Aetna
Important: Ohio residents have stronger external review rights than many states. The IRO decision is final and enforceable.

When to Contact Ohio Regulators

If Aetna delays or refuses to process your appeal:

  • Ohio Department of Insurance: 1-800-686-1526
  • File complaint online at insurance.ohio.gov (verify with the source)
  • ODI can order external review even if Aetna claims ineligibility

Counterforce Health helps patients and clinicians navigate these complex prior authorization challenges by analyzing denial letters, identifying the specific approval criteria, and drafting targeted appeals with the right clinical evidence and regulatory citations. Our platform streamlines the appeal process, saving time while improving approval rates for specialty medications like Tavneos.

Quick Audit Checklist

Before submitting your Tavneos PA request, verify:

Clinical Documentation:

  • Specific ICD-10 code (M31.31, M31.7, or I77.82)
  • ANCA lab results with values
  • Prior therapy documentation (tried/failed/contraindicated)
  • Specialist prescriber (rheum/neph/pulm)
  • Baseline liver function tests
  • Concurrent standard therapy plan

Billing Information:

  • Correct NDC: 73129-0101-01
  • Quantity: 180 capsules maximum per 30 days
  • Day supply: 30 days
  • Pharmacy benefit processing (not medical)

Submission Requirements:

  • Complete Aetna PA form
  • All required attachments
  • Correct fax number: 1-855-734-9389
  • Member eligibility verified
  • Prescriber DEA/NPI included

FAQ

How long does Aetna CVS Health prior authorization take for Tavneos in Ohio? Standard decisions take up to 10 calendar days. Urgent requests (when delay would jeopardize health) are decided within 48 hours. Source: Aetna Better Health Ohio.

What if Tavneos is non-formulary on my Aetna plan? You can request a formulary exception with clinical documentation showing medical necessity and lack of suitable alternatives. Use the same PA process but indicate "formulary exception" on the request form.

Can I request an expedited appeal if my Tavneos is denied? Yes, if your physician certifies that standard timing would seriously jeopardize your health. Expedited appeals are decided within 72 hours for internal appeals and external reviews.

Does step therapy apply to Tavneos with Aetna CVS Health? Most Aetna policies require documentation of standard therapy use (glucocorticoids with rituximab or cyclophosphamide) before approving Tavneos, since it's indicated as adjunctive treatment only.

What happens if I move from another state to Ohio? Your Aetna plan benefits remain the same, but Ohio's stronger external review laws will apply to any future appeals. You'll have 180 days for internal appeals and binding external review through Ohio's IRO system.

How much does Tavneos cost if approved by Aetna CVS Health? Your out-of-pocket cost depends on your plan's specialty tier copay or coinsurance. Tavneos typically costs $17,000+ per month at retail, but approved patients usually pay their specialty drug copay (often $50-500/month depending on plan).

Can my primary care doctor prescribe Tavneos? Most Aetna policies require prescribing by a rheumatologist, nephrologist, or pulmonologist. Primary care physicians typically cannot get approval for Tavneos.

What if my ANCA test was negative but I have biopsy-proven vasculitis? Some patients with GPA/MPA are ANCA-negative. Include the biopsy report showing necrotizing vasculitis and clinical presentation consistent with ANCA-associated vasculitis. The ICD-10 codes still apply.

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage decisions depend on your specific plan benefits and clinical circumstances. Always consult your healthcare provider and insurance plan for personalized guidance. For official Ohio insurance regulations and appeal rights, contact the Ohio Department of Insurance at 1-800-686-1526.

Sources & Further Reading

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