By Counterforce Health Team in Tysabri (natalizumab) —

How to Get Tysabri (Natalizumab) Covered by Aetna CVS Health in Texas: Complete Prior Authorization Guide

Answer Box: Fast Track to Tysabri Coverage in Texas

Getting Tysabri (natalizumab) covered by Aetna CVS Health in Texas requires completing the mandatory TOUCH Program enrollment first, then submitting prior authorization with JCV status, recent MRI results, and documentation of prior therapy failures. Start today: (1) Enroll in TOUCH at touchprogram.com or call 1-800-456-2255, (2) gather your recent labs and MRI within 3-6 months, (3) have your doctor submit PA via Aetna's provider portal or fax 1-888-267-3277. Standard decisions take 30-45 days; expedited urgent cases are decided within 24-72 hours.

Table of Contents

Verify Your Plan and Find the Right Forms

Before starting your Tysabri coverage request, confirm your specific Aetna plan type. Texas residents may have Aetna commercial plans, Medicare Advantage, or Medicaid managed care through Aetna Better Health of Texas. Each has different forms and processes.

Check your member ID card for plan details. Commercial and Medicare plans typically use CVS Caremark for specialty pharmacy benefits, while Medicaid plans may have different pharmacy networks. Call the member services number on your card to verify:

  • Whether Tysabri requires prior authorization
  • If it's covered under medical or pharmacy benefits
  • Your specific formulary tier and any step therapy requirements
Tip: Tysabri is usually covered under the medical benefit as an infused specialty drug, but 2026 formulary changes may shift some specialty drugs to pharmacy benefits for certain Aetna plans.

Required Forms and Documentation

TOUCH Program Enrollment (Mandatory First Step)

Tysabri cannot be prescribed, dispensed, or administered without completing the FDA-required TOUCH Prescribing Program. This applies to all parties:

For Prescribers:

  • Complete Prescriber Enrollment Form at touchprogram.com
  • Review Tysabri Patient Medication Guide
  • Enroll each patient via DocuSign process

For Patients:

  • Complete patient enrollment and consent forms
  • Provide JC virus antibody status and history
  • Consent to regular MRI monitoring

Timeline: Allow 2-3 business days for TOUCH approval before submitting insurance prior authorization.

Prior Authorization Documentation

Your doctor will need to gather and submit:

Document Type Requirements Source
Clinical notes Diagnosis confirmation (MS or Crohn's), ICD-10 codes Medical records
Prior therapies Documentation of failed/intolerated DMTs with dates Treatment history
JCV antibody status Recent test results (within 6 months preferred) Lab reports
MRI results Brain MRI within 3-6 months showing disease activity Imaging reports
TOUCH confirmation Enrollment confirmation numbers for all parties TOUCH portal

Submission Portals and Methods

Online Portals

For Providers:

  • Availity Portal: Primary submission method for Aetna prior authorizations
  • CVS Specialty Portal: For specialty pharmacy coordination
  • TOUCH On-Line: For patient monitoring and documentation at touchprogram.com/TTP

For Members:

  • Aetna member portal for tracking PA status
  • CVS Caremark portal for pharmacy benefit management

Electronic Prior Authorization (ePA)

Most efficient submission method through provider EHR systems integrated with Aetna's ePA platform. Allows real-time status tracking and faster processing.

Fax Numbers and Mailing Addresses

Aetna CVS Health Contacts

Prior Authorization Fax: 1-888-267-3277
General Inquiries: 1-866-752-7021
Expedited/Urgent Cases: Same fax with "URGENT" clearly marked

TOUCH Program Contacts

Questions/Support: 1-800-456-2255 (Mon-Fri 8:30 AM-8 PM ET)
JCV History Consent Fax: 1-800-840-1278

Cover Sheet Best Practices

When faxing, include:

  • Member name and ID number
  • Provider name and NPI
  • "Prior Authorization Request - Tysabri (natalizumab)"
  • Urgency level (standard or expedited)
  • Complete page count

CVS Specialty Pharmacy Setup

Since most Aetna plans use CVS Specialty for infused medications like Tysabri, coordinate enrollment early:

  1. Provider completes CVS Specialty MS Infusion Enrollment Form
  2. Indicate CVS Specialty as preferred pharmacy on TOUCH forms
  3. Verify network status - using in-network specialty pharmacies maximizes coverage
  4. Consider QuickStart Program - up to 3 free doses while PA processes (verify eligibility)

CVS Specialty Contact: 1-800-237-2767

Note: Texas law prohibits insurers from mandating "white bagging" (external pharmacy shipping to provider), preserving provider buy-and-bill options where applicable.

Support Lines and Contacts

Texas-Specific Aetna Contacts

Aetna Better Health of Texas (Medicaid):

  • STAR (Bexar area): 1-800-248-7767
  • STAR (Tarrant area): 1-800-306-8612
  • STAR Kids: 1-844-787-5437 (press 2 for case management)

General Aetna Member Services: Number on your member ID card

Case Management and Utilization Review

For complex cases requiring case management support:

  • Call member services for referral to case management
  • Request peer-to-peer review if initial PA is denied
  • Ask about expedited review for urgent medical situations

Texas Appeals and External Review

Internal Appeals Process

If your Tysabri PA is denied, you have 180 days to file an internal appeal with Aetna:

Submission Methods:

  • Phone: Member services number on your ID card
  • Fax: Include completed Request for Coverage Decision Form
  • Online: Through Aetna member portal
  • Mail: Address provided in denial notice

Required Documentation:

  • Original denial letter
  • Prescriber's medical necessity letter
  • Additional clinical evidence supporting Tysabri need
  • Documentation of formulary alternatives tried/failed

Decision Timeline:

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

Texas External Review (IRO)

After exhausting internal appeals, Texas residents can request Independent Review Organization (IRO) review through the Texas Department of Insurance:

Eligibility: Denials based on medical necessity, appropriateness, or experimental/investigational determinations

Process:

  1. Complete Form LHL009 (Request for Review by IRO)
  2. Submit to Aetna within 45 calendar days of final denial
  3. Aetna forwards to TDI within 1 business day
  4. IRO assigned and reviews case
  5. Binding decision issued within 20 days (standard) or 8 days (life-threatening)

No cost to patients for most IRO reviews. Download forms at TDI IRO requests page.

Texas Consumer Assistance

Texas Department of Insurance: 1-800-252-3439
Office of Public Insurance Counsel (OPIC): 1-877-611-6742
TDI IRO Information Line: 1-866-554-4926

Common Denial Reasons and Solutions

Denial Reason Solution Strategy Required Documentation
Missing TOUCH enrollment Complete all TOUCH requirements first Confirmation numbers for prescriber, patient, infusion site
Inadequate prior therapy documentation Provide detailed failure/intolerance records Treatment dates, reasons for discontinuation, side effects
Missing or outdated MRI Obtain recent brain MRI showing active disease MRI report within 3-6 months with radiologist interpretation
JCV status not provided Submit recent JCV antibody test results Lab report with index value and risk stratification
Step therapy requirement Document medical necessity for bypassing Clinical rationale why alternatives inappropriate
Quantity or frequency limits Justify dosing based on FDA labeling Prescriber attestation of standard 300mg IV q4w dosing

Costs and Financial Assistance

Manufacturer Support Programs

Biogen Free Drug Program: For eligible uninsured patients
Tysabri Co-pay Program: May reduce out-of-pocket costs for commercially insured patients
QuickStart Program: Up to 3 free doses while insurance processes

Contact: 1-800-456-2255 or visit Tysabri.com for current eligibility requirements

Additional Resources

  • Patient Access Network Foundation: Grants for specialty drug copays
  • HealthWell Foundation: Financial assistance for chronic conditions
  • Texas Health and Human Services: For Medicaid coverage questions

When Counterforce Health helps patients navigate insurance denials, we see that having comprehensive documentation from the start significantly improves approval rates. Our platform automatically identifies the specific denial reasons and creates targeted appeals that address Aetna's coverage criteria point-by-point, incorporating the right clinical evidence and payer-specific requirements. For complex cases like Tysabri, where TOUCH program compliance and detailed clinical documentation are critical, having an organized approach to gathering and presenting evidence can make the difference between approval and denial.

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take for Tysabri in Texas?
Standard PA decisions take 30-45 days. Expedited requests for urgent cases are decided within 24-72 hours. TOUCH enrollment (required first) takes 2-3 business days.

What if Tysabri is non-formulary on my Aetna plan?
Request a formulary exception with your doctor's medical necessity letter documenting why formulary alternatives are inappropriate. Include clinical evidence and guideline support.

Can I request an expedited appeal if denied?
Yes, if a delay would jeopardize your health or ability to regain maximum function. Mark appeals "URGENT" and provide clinical justification for expedited review.

Does step therapy apply if I've already failed other DMTs outside Texas?
Previous treatment failures should count regardless of location. Provide complete treatment records with dates, medications tried, and reasons for discontinuation.

What happens if my appeal is denied by Aetna?
Texas residents can request binding external review through an Independent Review Organization (IRO) via the Texas Department of Insurance within 45 days.

Is there financial assistance if I can't afford Tysabri?
Yes, Biogen offers patient assistance programs, and several foundations provide grants for specialty drug copays. Contact 1-800-456-2255 for eligibility screening.

Can I use any infusion center for Tysabri?
Only TOUCH-certified infusion sites can administer Tysabri. CVS Specialty can help coordinate with certified locations in your area.

What if my doctor isn't enrolled in TOUCH?
Your doctor must complete TOUCH enrollment before prescribing Tysabri. The process takes 2-3 days and includes required education modules. Start at touchprogram.com.

This article provides educational information and is not medical advice. Always consult your healthcare provider for medical decisions. For personalized assistance with insurance appeals and prior authorizations, Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies, coverage criteria, and appeal processes may change. Always verify current requirements with your insurer and consult healthcare professionals for medical decisions.

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