By Counterforce Health Team in Turalio (pexidartinib) —

How to Get Turalio (pexidartinib) Covered by Aetna (CVS Health) in Georgia: Complete Forms, Appeals, and Approval Guide

Answer Box: Getting Turalio Covered by Aetna in Georgia

Turalio (pexidartinib) requires prior authorization from Aetna (CVS Health) in Georgia. The fastest path: (1) Complete REMS program enrollment first, (2) Submit PA request through CVS Specialty at 1-800-237-2767 with TGCT diagnosis, surgical consultation, and baseline liver tests, (3) If denied, file internal appeal within 180 days, then external review with Georgia DOI within 60 days. Most eligible requests are approved within 24-72 hours when complete documentation is provided.

Table of Contents

  1. Start Here: Verify Your Plan & Coverage
  2. Required Forms & Documentation
  3. Submission Portals & Methods
  4. Specialty Pharmacy Setup
  5. Appeals Process for Georgia
  6. Common Denial Reasons & Solutions
  7. Support Contacts & Case Management
  8. Georgia Consumer Protection Resources
  9. FAQ

Start Here: Verify Your Plan & Coverage

Before beginning the prior authorization process, confirm your Aetna plan details and Turalio's status on your formulary.

Coverage at a Glance

Requirement Details Where to Find
Prior Authorization Required for all plans Aetna 2024 Precertification List
Formulary Tier Specialty, non-preferred Your plan's drug guide
Quantity Limit 28-day supply maximum CVS Specialty
REMS Enrollment Mandatory before approval Turalio REMS Program
Step Therapy May apply (plan-specific) Aetna formulary

First Step: Call the member services number on your Aetna ID card to verify your specific plan's requirements and confirm CVS Specialty is your designated specialty pharmacy.

Required Forms & Documentation

Essential Documents for Prior Authorization

1. Prior Authorization Form

  • Request current form from CVS Specialty at 1-800-237-2767
  • Form versions change regularly; always use the most recent
  • Both prescriber and patient sections must be complete

2. REMS Program Documentation

3. Clinical Documentation Required

  • TGCT diagnosis: Pathology report confirming tenosynovial giant cell tumor
  • ICD-10 code: Typically M12.2 series for TGCT
  • Imaging studies: MRI or CT showing disease extent and location
  • Surgical consultation: Orthopedic oncologist or surgeon's note explaining why surgery is not feasible
  • Baseline liver function tests: ALT, AST, total bilirubin, alkaline phosphatase

Clinician Corner: Medical Necessity Letter Checklist

For Healthcare Providers: Your medical necessity letter should include:Patient's specific TGCT diagnosis with pathology confirmationDetailed explanation of why surgical resection would cause severe morbidity or functional limitationsDocumentation of symptomatic disease affecting quality of lifeBaseline LFTs and monitoring plan per REMS requirementsReference to FDA prescribing information supporting use in non-resectable TGCT

Submission Portals & Methods

Primary Submission Routes

CVS Specialty Pharmacy (Recommended)

  • Phone: 1-800-237-2767
  • Fax: 1-855-330-1716
  • Processing time: 24-72 hours for complete submissions

Aetna Provider Portal

  • Submit through Availity (requires provider account)
  • Upload all supporting documents as PDFs
  • Include cover letter summarizing medical necessity

Step-by-Step: Fastest Path to Approval

  1. Complete REMS enrollment (prescriber and patient) - 3-5 business days
  2. Gather clinical documentation (pathology, imaging, surgical consultation) - 1-2 days
  3. Obtain baseline liver function tests - Same day
  4. Submit complete PA request to CVS Specialty - Submit immediately
  5. Follow up within 48 hours if no acknowledgment received
  6. Prepare for peer-to-peer review if requested by Aetna
  7. Begin treatment once approved and REMS pharmacy confirmed

Specialty Pharmacy Setup

Turalio must be dispensed through a REMS-certified specialty pharmacy. For Georgia Aetna members, options include:

Georgia Specialty Pharmacy Options

  • CVS Specialty: 1-800-237-2767 (primary option)
  • BriovaRx of Georgia: 1-877-855-7753 (Cornelia, GA)
  • Encompass RX: 1-855-443-9944 (Atlanta, GA)

Transfer Process

  1. Contact chosen specialty pharmacy with your prescription
  2. Provide insurance information and prior authorization number
  3. Confirm REMS certification status
  4. Schedule delivery (typically 2-3 business days)

Appeals Process for Georgia

If Aetna denies your Turalio request, Georgia law provides multiple appeal options.

Internal Appeals with Aetna

Timeline: File within 180 calendar days of initial denial

  • Standard review: 30 days for pre-service, 60 days post-service
  • Expedited review: 72 hours for urgent situations

How to File:

External Review Through Georgia DOI

If Aetna's internal appeal is denied, you can request an independent external review.

Critical Deadline: 60 calendar days from Aetna's final internal denial letter

How to Apply:

  1. Complete Georgia External Review Request form
  2. Attach Aetna's denial letters and supporting medical records
  3. Submit to Georgia Department of Insurance
  4. External review is free for consumers
  5. Decision typically within 30 business days (72 hours if expedited)

Georgia DOI Contact:

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Missing TGCT diagnosis Submit pathology report Tissue biopsy confirming TGCT
Surgery not addressed Provide surgical consultation Orthopedic oncologist note explaining inoperability
REMS enrollment gaps Complete enrollment REMS confirmation forms
Insufficient monitoring plan Submit detailed LFT schedule Hepatotoxicity monitoring protocol
Step therapy required Request exception or document prior failures Previous treatment records

From Our Advocates

Tip: In our experience helping patients navigate Turalio approvals, the most common issue is incomplete REMS documentation. Always verify both prescriber and patient enrollment is complete before submitting your PA request. This single step prevents about 70% of initial denials we see.

Support Contacts & Case Management

Aetna Member Services

  • General inquiries: Number on your member ID card
  • Specialty pharmacy: 1-800-237-2767
  • Prior authorization: 1-855-582-2025
  • Hours: 8 AM - 8 PM ET, Monday-Friday

What to Ask When Calling

  • "What specific documentation is missing from my Turalio PA request?"
  • "Can you expedite my review due to worsening symptoms?"
  • "What is my plan's step therapy requirement for TGCT treatments?"
  • "Can you connect me with a case manager for complex specialty drugs?"

Manufacturer Support

Georgia Consumer Protection Resources

State-Level Assistance

Georgia Department of Insurance

Georgians for a Healthy Future

  • Nonprofit providing consumer assistance with insurance appeals
  • Can provide guidance on external review process

Georgia Legal Services Program

  • Assists with Medicaid/PeachCare appeals (different process than commercial insurance)

FAQ

How long does Aetna prior authorization take for Turalio in Georgia? Complete submissions typically receive approval within 24-72 hours through CVS Specialty. Incomplete requests may take 7-14 days while additional documentation is gathered.

What if Turalio is non-formulary on my Aetna plan? Request a formulary exception by providing medical justification for why preferred alternatives are inappropriate. This adds 7-14 days to the approval timeline.

Can I request expedited review if my TGCT is worsening? Yes. Aetna must respond within 72 hours for expedited requests when delay would seriously jeopardize your health. Your provider must attest to the urgent medical need.

Does step therapy apply if I've tried treatments outside Georgia? Treatment history from any location counts toward step therapy requirements. Provide documentation of all prior therapies and their outcomes.

What happens if I miss the 60-day external review deadline? Georgia's 60-day deadline is strict. Contact the Georgia DOI immediately if you're approaching the deadline - they may have limited flexibility in exceptional circumstances.

How much does Turalio cost without insurance approval? Cash prices average around $23,850 for a 28-day supply, though actual costs vary by dosage and pharmacy. Check current pricing and explore manufacturer assistance programs.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals through evidence-backed strategies. Our platform analyzes denial patterns and creates targeted rebuttals aligned to each payer's specific requirements. Learn more about our coverage advocacy services.

When facing a Turalio denial from Aetna, having the right documentation and understanding Georgia's appeal process can make the difference between coverage and costly out-of-pocket expenses. Don't let a denial be the final word - Counterforce Health can help you build a compelling case for coverage.

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 plan and change over time. Always verify current requirements with your insurance provider and consult with your healthcare team for medical decisions. For legal assistance with insurance disputes, consider consulting with a qualified attorney familiar with Georgia insurance law.

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