By Counterforce Health Team in Trikafta / Kaftrio (elexacaftor/tezacaftor/ivacaftor) —

How to Get Trikafta Covered by Aetna CVS Health in California: Complete Prior Authorization and Appeals Guide 2024

Answer Box: Fastest Path to Trikafta Approval

Trikafta requires prior authorization from Aetna CVS Health in California. Submit CFTR genotype results showing F508del mutation, baseline liver function tests, and CF specialist attestation through Aetna's provider portal. Standard approval takes 5-10 business days. If denied, file internal appeal within 180 days, then request California's Independent Medical Review (IMR) which overturns 68% of specialty drug denials. Start today: Have your CF specialist gather genetic test results and submit the prior authorization request with complete documentation.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Timeline
Prior Authorization Required for all Aetna plans Aetna PA portal 5-10 business days
CFTR Genotype F508del or eligible mutation documented CLIA-certified lab report Must submit with PA
Age Requirement Patient ≥2 years old Birth certificate/medical records Must document
CF Specialist Pulmonologist or CF specialist must prescribe Provider credentials Required for PA
Baseline Labs Liver function tests (ALT, AST, bilirubin) Recent lab results Within 6 months
Formulary Status Specialty tier, requires PA Aetna formulary Check annually

Step-by-Step: Fastest Path to Approval

1. Confirm Eligibility and Gather Documentation

Who does it: Patient and CF care team
Timeline: 1-2 weeks before PA submission

  • Obtain CFTR genetic test results showing F508del or eligible mutation
  • Schedule baseline liver function tests if not recent
  • Collect previous CF therapy records (for step therapy documentation)
  • Verify Aetna coverage and specialty pharmacy requirements

2. Complete Prior Authorization Request

Who does it: CF specialist or clinic staff
Timeline: Same day as submission

Your CF specialist submits the PA request via Aetna's provider portal or by calling 1-888-632-3862. Required documentation includes:

  • CFTR genotype lab report
  • CF diagnosis with ICD-10 code (E84.0-E84.9)
  • Baseline liver function tests
  • Clinical notes supporting medical necessity
  • Age verification
  • Specialist attestation letter

3. CVS Specialty Pharmacy Enrollment

Who does it: Patient with clinic support
Timeline: After PA approval

Complete the CVS Specialty enrollment form for cystic fibrosis oral therapies. The pharmacy coordinates with Aetna for coverage verification and handles ongoing refills.

4. Monitor PA Decision

Who does it: Clinic staff and patient
Timeline: 5-10 business days (72 hours if expedited)

Track the PA status through Aetna's portal. California law requires responses within specific timeframes:

  • Standard PA: 5-10 business days
  • Expedited PA (urgent medical need): 72 hours
  • Formulary exception: 72 hours (24 hours if urgent)
Tip: If Aetna doesn't respond within the required timeframe, the request is automatically approved under California law.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Missing genotype Submit CFTR genetic test CLIA-certified lab report showing F508del
Age restrictions Provide birth certificate Documentation showing patient ≥2 years
Non-formulary status Request formulary exception Medical necessity letter with guidelines
Step therapy Document prior CF therapy failures Treatment history and intolerance records
Quantity limits Justify dosing per FDA label Weight-based calculations and specialist notes
Missing baseline labs Submit recent lab results ALT, AST, bilirubin within 6 months

Appeals Playbook for California

Internal Appeal with Aetna

Deadline: 180 days from denial
Timeline: 30 days (72 hours if expedited)
How to file: Aetna member portal or written request

Submit your appeal with:

  • Complete denial letter
  • All medical records supporting Trikafta necessity
  • CF specialist's detailed statement
  • Updated lab results or clinical notes

California Independent Medical Review (IMR)

Deadline: 6 months after final internal denial
Timeline: 45 days (7 days if expedited)
How to file: healthhelp.ca.gov or 888-466-2219
Cost: Free to patients

California's IMR process has a 68% success rate for overturning specialty drug denials. The Department of Managed Health Care assigns an independent physician reviewer who makes a binding decision.

From our advocates: We've seen Trikafta denials reversed within days when patients submit complete genetic testing results and specialist letters together. The key is addressing the specific denial reason with targeted evidence rather than submitting general medical records.

Expedited Reviews for Urgent Cases

If delay poses serious health risks:

  • Internal appeal: 72 hours
  • IMR: 7 days or less
  • Direct IMR: Skip internal appeal if immediate threat exists

Costs and Patient Assistance

List Price: Approximately $369,000 annually
Typical Patient Cost: Varies by plan; specialty tier copays often $50-$200+ monthly

Patient Assistance Options

  • Vertex Patient Services: Copay assistance and financial support
  • CF Foundation Compass: Insurance navigation and financial assistance
  • California state programs: Medi-Cal coverage for eligible patients

When to Escalate to State Regulators

Contact the California Department of Managed Health Care if:

  • Aetna misses response deadlines
  • Appeals process isn't followed properly
  • You need help filing an IMR

DMHC Help Center: 888-466-2219
Website: dmhc.ca.gov

The DMHC can intervene directly with health plans and assist with the IMR process.

Frequently Asked Questions

Q: How long does Aetna prior authorization take in California?
A: Standard PAs take 5-10 business days. Expedited requests must be decided within 72 hours per California law.

Q: What if Trikafta isn't on Aetna's formulary?
A: Request a formulary exception. Aetna must respond within 72 hours (24 hours if urgent). No response equals automatic approval.

Q: Can I request an expedited appeal?
A: Yes, if delay poses serious health risks. Expedited internal appeals get 72-hour decisions; expedited IMR takes 7 days or less.

Q: Do I need to try other CF medications first?
A: This depends on your genotype and prior treatment history. Document any previous CF therapies and their outcomes.

Q: What happens if my appeal is denied?
A: Request California's Independent Medical Review (IMR). It's free, binding, and overturns 68% of specialty drug denials.

Q: Can I get help with the appeals process?
A: Yes. Counterforce Health specializes in turning insurance denials into targeted appeals for specialty medications like Trikafta.

Checklist: What to Gather Before You Start

Insurance Information:

  • Aetna member ID and policy details
  • Current formulary and benefits summary
  • Specialty pharmacy requirements

Medical Documentation:

  • CFTR genetic test results
  • CF diagnosis and ICD-10 codes
  • Baseline liver function tests (within 6 months)
  • Previous CF therapy records
  • Current clinical notes and PFTs

Provider Information:

  • CF specialist contact information
  • Provider NPI and credentials
  • Clinic's PA submission process

Getting professional help with complex denials: 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 draft point-by-point rebuttals aligned with payer requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and should not be considered medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with Aetna and consult your healthcare provider for medical decisions. For assistance with California insurance regulations, contact the DMHC Help Center at 888-466-2219.

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