By Counterforce Health Team in Vitrakvi (larotrectinib) —

How to Get Vitrakvi (Larotrectinib) Covered by Aetna CVS Health in Washington: PA Forms, Appeals, and Cost-Saving Strategies

Answer Box: Getting Vitrakvi Covered by Aetna CVS Health in Washington

Aetna CVS Health requires prior authorization for Vitrakvi (larotrectinib) with NTRK gene fusion testing documentation. Submit PA via CVS Specialty at 1-888-267-3277 with molecular pathology report showing NTRK1/2/3 fusion, oncologist prescription, and staging records. If denied, Washington residents have 180 days for internal appeals and 120 days for external review through the Office of Insurance Commissioner's IRO process. Start today: Call CVS Specialty to confirm PA requirements and request forms.

Table of Contents

  1. What Drives Vitrakvi Costs with Aetna CVS Health
  2. Benefit Investigation: Key Questions to Ask
  3. Assistance Options: Manufacturer and Foundation Support
  4. Prior Authorization Requirements and Process
  5. Appeals Process in Washington State
  6. Pharmacy Choice and Coordination
  7. Renewal Planning and Annual Changes
  8. Conversation Scripts
  9. FAQ

What Drives Vitrakvi Costs with Aetna CVS Health

Vitrakvi's annual cost of approximately $394,000 at standard adult dosing makes it a specialty tier medication requiring careful navigation of Aetna CVS Health's benefit design. Your out-of-pocket costs depend on several factors:

Formulary Tier Placement:

  • Preferred Specialty (PSP): Lower copays, typically $50-200/month
  • Non-Preferred Specialty (NPSP): Higher costs, often 25-40% coinsurance
  • Non-formulary: Requires exception request with full documentation

Coverage Requirements:

Requirement Impact on Cost Documentation Needed
Prior Authorization Denial without proper submission NTRK fusion report, oncologist notes
Specialty Pharmacy Out-of-network penalties apply Must use CVS Specialty
Medical Necessity Coverage denial if criteria not met Treatment history, staging imaging
Note: Aetna CVS Health manages Vitrakvi exclusively through CVS Specialty Pharmacy, making proper coordination essential for coverage.

Benefit Investigation: Key Questions to Ask

Before starting the approval process, gather this critical information from Aetna CVS Health:

Call Member Services (number on your insurance card):

  1. "What is Vitrakvi's formulary tier on my specific plan?"
  2. "What's my specialty medication copay or coinsurance?"
  3. "Is prior authorization required, and what documentation is needed?"
  4. "Are there quantity limits or step therapy requirements?"
  5. "What's my annual out-of-pocket maximum for specialty drugs?"

Record This Information:

  • Policy/member ID number
  • Group number (if employer-sponsored)
  • Plan type (HMO, PPO, Medicare Advantage)
  • Specialty pharmacy network requirements
  • Appeals deadline (typically 180 days in Washington)

Verify Coverage Limits: Check if your plan has annual or lifetime maximums for specialty medications, as some older plans may have caps that could affect long-term Vitrakvi coverage.

Assistance Options: Manufacturer and Foundation Support

TRAK Assist Program (Bayer/Lilly): The manufacturer offers comprehensive support for Vitrakvi patients, including:

  • $0 Copay Program: Covers copays up to $15,000/year for commercially insured patients
  • Prior Authorization Support: Dedicated team helps with PA submissions and appeals
  • Bridge Therapy: Temporary supply during insurance processing
  • Eligibility: Commercial insurance required (excludes Medicare, Medicaid, VA)

How to Enroll:

  1. Call TRAK Assist at 1-866-581-4992
  2. Provide insurance information and prescription details
  3. Complete financial screening (annual income verification)
  4. Receive copay card and program materials

Independent Foundation Grants: For patients with government insurance or those who don't qualify for manufacturer programs:

  • Patient Access Network Foundation: Disease-specific grants for NTRK+ tumors
  • CancerCare Co-Payment Assistance: Income-based support program
  • Good Days: Chronic disease assistance (verify NTRK tumor eligibility)
From Our Advocates: "We've seen patients reduce their monthly Vitrakvi costs from $1,500+ to $25 by combining manufacturer copay assistance with proper insurance navigation. The key is applying for assistance programs before your first fill, as some have enrollment deadlines."

Prior Authorization Requirements and Process

Required Documentation for Aetna CVS Health PA:

Document Type Specific Requirements Source
NTRK Fusion Testing RNA-NGS showing NTRK1/2/3 fusion with specific partner CLIA/CAP-validated lab
Pathology Report ≥10% tumor content, histologic confirmation Hospital pathology department
Staging Studies CT/MRI showing metastatic or unresectable disease Radiology reports
Treatment History Prior therapies tried, dates, responses, discontinuation reasons Oncology clinic notes
Prescriber Attestation Medical oncologist signature and DEA number Treating physician

Step-by-Step PA Submission:

  1. Order NTRK Testing (if not done): Request RNA-NGS panel from Mayo Clinic, Cleveland Clinic, or NeoGenomics
  2. Gather Documentation: Collect all required reports and clinical notes
  3. Submit PA to CVS Specialty: Fax complete packet to 1-888-267-3277
  4. Track Submission: Use CVS Caremark provider portal for status updates
  5. Follow Up: Call CVS Specialty within 3 business days to confirm receipt

Timeline Expectations:

  • Standard PA decision: 15 business days
  • Expedited review (urgent cases): 72 hours
  • Incomplete submissions: Additional 10-15 days for resubmission

Appeals Process in Washington State

If Aetna CVS Health denies your Vitrakvi coverage, Washington state provides strong consumer protections through a multi-level appeals process.

Internal Appeals with Aetna:

Level 1 Appeal (file within 180 days):

  • Submit to: Aetna Appeals Resolution Team, PO Box 14463, Lexington, KY 40512
  • Fax: 1-859-425-3379
  • Include: Denial letter, medical records, physician letter, NTRK fusion report
  • Timeline: 30-45 days for decision

Level 2 Appeal (file within 60 days of Level 1 denial):

  • Same submission process as Level 1
  • Include additional evidence: peer-reviewed studies, FDA labeling, treatment guidelines
  • Consider requesting peer-to-peer review with Aetna medical director

Expedited Appeals (for urgent cases):

  • Call 1-877-665-6736 for medical appeals
  • Timeline: 36-72 hours for decision
  • Use when treatment delay could harm your health

External Review Through Washington OIC:

If internal appeals fail, Washington residents can request Independent Review Organization (IRO) review:

Eligibility:

  • Fully insured Aetna plan (not self-funded employer plans)
  • Exhausted internal appeals or received final adverse determination
  • File within 120 days of final internal denial

How to File:

  1. Complete OIC's "Request for External Review" form at insurance.wa.gov
  2. Submit with denial letters, medical records, and supporting evidence
  3. OIC assigns IRO randomly within 5 business days
  4. IRO reviews case and issues binding decision within 45 days

Contact Washington OIC:

  • Consumer Assistance: 1-800-562-6900
  • Website: insurance.wa.gov/external-review
  • No cost to file external review
Tip: Washington's external review process has strong success rates for rare disease medications with solid FDA approval and clinical evidence. The IRO's decision is binding on Aetna.

Pharmacy Choice and Coordination

CVS Specialty Pharmacy Requirements: Aetna CVS Health requires Vitrakvi to be dispensed through CVS Specialty Pharmacy. Using other pharmacies will result in coverage denial or significantly higher costs.

CVS Specialty Coordination:

  • Enrollment: Your prescriber must enroll via CVS Specialty provider portal
  • Patient Registration: Call 1-888-267-3277 to set up delivery preferences
  • Refill Management: CVS Specialty contacts you before each refill
  • Clinical Support: Dedicated pharmacists available for questions

Delivery Options:

  • Standard shipping: 2-3 business days (free)
  • Expedited shipping: Next business day ($15-25 fee)
  • Signature required for all deliveries

Coordination with TRAK Assist: If enrolled in the manufacturer copay program, provide your CVS Specialty pharmacist with your TRAK Assist card information to ensure proper billing coordination.

Renewal Planning and Annual Changes

Annual Open Enrollment Considerations: Plan benefits can change each January 1st. Review these items during open enrollment:

  • Formulary Changes: Vitrakvi's tier placement may shift
  • Prior Authorization: Requirements may become more or less stringent
  • Copay Amounts: Specialty medication costs often increase annually
  • Network Changes: Confirm CVS Specialty remains in-network

Mid-Year Changes to Monitor:

  • Formulary Updates: Aetna can remove drugs with 60 days' notice
  • Policy Changes: PA criteria may be updated quarterly
  • Generic Availability: No generic Vitrakvi expected before 2028

Budgeting Tips:

  • Track total out-of-pocket spending toward annual maximums
  • Renew manufacturer copay assistance annually (typically January)
  • Consider Flexible Spending Account or Health Savings Account contributions

Conversation Scripts

Calling Aetna Member Services: "Hi, I need to verify coverage for Vitrakvi, spelled V-I-T-R-A-K-V-I, for an NTRK-positive cancer. Can you tell me the formulary tier, prior authorization requirements, and my expected copay? My member ID is [number]."

CVS Specialty Enrollment Call: "My oncologist prescribed Vitrakvi and I need to set up specialty pharmacy services. I have Aetna CVS Health insurance and want to confirm all prior authorization requirements before my doctor submits the prescription."

TRAK Assist Program Call: "I'd like to apply for the Vitrakvi copay assistance program. I have commercial insurance through Aetna CVS Health and my oncologist has prescribed Vitrakvi for an NTRK-positive tumor. What information do you need to determine my eligibility?"

Peer-to-Peer Request Script for Clinic Staff: "I'm calling to request a peer-to-peer review for a Vitrakvi prior authorization denial. The patient has a confirmed NTRK fusion-positive solid tumor, has failed standard therapies, and meets all FDA labeling criteria. When can your medical director speak with our oncologist?"

Counterforce Health helps patients and clinicians navigate complex insurance denials by turning rejection letters into targeted, evidence-backed appeals. Our platform analyzes denial reasons and drafts point-by-point rebuttals aligned with each payer's specific policies and requirements.

FAQ

How long does Aetna CVS Health prior authorization take for Vitrakvi in Washington? Standard PA decisions take 15 business days. Expedited reviews for urgent cases are completed within 72 hours. Incomplete submissions add 10-15 days for reprocessing.

What if Vitrakvi is non-formulary on my Aetna plan? Request a formulary exception with your PA submission. Include the NTRK fusion report, treatment history, and medical necessity letter explaining why Vitrakvi is the only appropriate option for your specific tumor type.

Can I request an expedited appeal if my cancer is progressing? Yes. Call Aetna's expedited appeals line at 1-877-665-6736. Provide documentation from your oncologist stating that treatment delay could harm your health. Expedited appeals are decided within 36-72 hours.

Does step therapy apply to Vitrakvi for NTRK-positive tumors? Generally no, due to Vitrakvi's unique mechanism and tumor-agnostic FDA approval. However, Aetna may require documentation of prior standard therapies for your specific cancer type unless contraindicated.

What happens if I move out of Washington while on Vitrakvi? Your Aetna coverage terms remain the same, but state appeal rights change. Contact your new state's insurance commissioner for external review procedures if needed.

How much will Vitrakvi cost with the TRAK Assist copay program? Eligible patients typically pay $0-25/month with the program, which covers up to $15,000/year in copays and coinsurance. The program excludes government insurance (Medicare, Medicaid).

Can my local oncologist prescribe Vitrakvi, or do I need a specialist? While any licensed physician can prescribe Vitrakvi, Aetna CVS Health typically requires a medical oncologist or hematologist-oncologist for coverage approval. Community oncologists usually qualify if they're treating your cancer.

What if my NTRK fusion test was done at an outside lab? Aetna accepts NTRK fusion results from any CLIA/CAP-certified laboratory. Ensure the report clearly states the specific fusion (e.g., ETV6-NTRK3) and uses RNA-based testing methodology for best coverage outcomes.

For additional support navigating insurance challenges with rare disease medications, Counterforce Health provides specialized assistance in converting denials into successful appeals through targeted, evidence-based advocacy.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with Aetna CVS Health directly and consult with your healthcare team for medical decisions. For personalized assistance with insurance appeals and prior authorizations, contact the Washington Office of Insurance Commissioner at 1-800-562-6900.

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