By Counterforce Health Team in Acthar Gel (repository corticotropin injection) —

Lowering Out-of-Pocket Costs for Acthar Gel with Aetna CVS Health in Michigan: Complete Coverage & Assistance Guide

Answer Box: Getting Acthar Gel Covered by Aetna CVS Health in Michigan

Acthar Gel requires prior authorization from Aetna CVS Health in Michigan, with strict step therapy requiring documented failure of corticosteroids first. Your fastest path to approval: (1) Gather complete records of prior corticosteroid trials and outcomes, (2) Have your specialist submit a comprehensive medical necessity letter via Aetna's provider portal, and (3) Apply for Mallinckrodt's copay assistance (up to $15,000/year for commercial plans) while awaiting approval. If denied, you have 180 days to appeal internally, then can request external review through Michigan DIFS within 127 days.

Start today: Contact your prescribing physician to begin the PA documentation process and call Acthar Patient Support at 1-888-435-2284 to initiate financial assistance screening.

Table of Contents

  1. What Drives Acthar Gel Costs
  2. Benefit Investigation: What to Ask Aetna CVS Health
  3. Assistance Options: Copay Programs and Foundations
  4. Getting Prior Authorization Approved
  5. Specialty Pharmacy Coordination
  6. Appeals Process in Michigan
  7. Annual Renewal and Budget Planning
  8. Conversation Scripts
  9. FAQ

What Drives Acthar Gel Costs

Acthar Gel (repository corticotropin injection) is one of the most expensive specialty medications on the market, with a single 5-mL vial costing tens of thousands of dollars. Several factors determine your out-of-pocket costs with Aetna CVS Health:

Formulary Tier Placement

  • Acthar Gel is typically placed on the highest specialty tier (Tier 4 or 5)
  • Your coinsurance may be 25-50% of the drug cost
  • Some plans have specialty copay caps ($150-500/month maximum)

Medical vs. Pharmacy Benefit

  • Acthar dispensed through CVS Specialty Pharmacy typically falls under pharmacy benefit
  • Self-administered injections at home use pharmacy benefit coinsurance
  • Provider-administered doses may be covered under medical benefit with different cost-sharing

Prior Authorization Requirements Aetna CVS Health requires PA for all Acthar Gel prescriptions, with documentation of:

  • FDA-approved diagnosis with ICD-10 codes
  • Failed trial of corticosteroids (specific doses, durations, outcomes)
  • Medical necessity justification from a specialist
  • Treatment goals and monitoring plan
Tip: Request a benefits investigation before starting treatment to understand your exact coverage terms and out-of-pocket costs.

Benefit Investigation: What to Ask Aetna CVS Health

Contact Aetna Member Services at 1-800-872-3862 (commercial) or check your online member portal to gather this essential information:

Coverage Details to Record

  • Is Acthar Gel covered on your formulary? What tier?
  • What's your specialty medication coinsurance percentage?
  • Is there a specialty copay maximum per prescription or per month?
  • Does your plan have an out-of-pocket maximum that includes specialty drugs?
  • Are you subject to a separate specialty deductible?

Prior Authorization Status

  • What specific PA criteria must be met?
  • Which forms does your prescriber need to submit?
  • What documentation is required (clinical notes, lab results, prior therapy records)?
  • How long does the PA review typically take?

Pharmacy Network

  • Is CVS Specialty Pharmacy in-network for your plan?
  • Can you use other specialty pharmacies, or is CVS mandatory?
  • Are there different cost-sharing rules for different pharmacies?

Keep detailed notes from these calls, including representative names and reference numbers.

Assistance Options: Copay Programs and Foundations

Mallinckrodt Commercial Copay Program

Eligibility Requirements:

  • Must have commercial (private) insurance coverage for Acthar Gel
  • Cannot be enrolled in government programs (Medicare, Medicaid, TRICARE, VA)
  • Plan cannot use accumulator/maximizer programs that block manufacturer assistance
  • Must be enrolled personally (not through insurance agent or employer)

Benefits:

  • Up to $15,000 per calendar year toward out-of-pocket costs
  • Covers copays, coinsurance, and deductibles
  • Cannot be used for insurance premiums or reimbursed by third parties

How to Apply: Call Acthar Patient Support at 1-888-435-2284 or visit Counterforce Health for assistance with enrollment and documentation.

Patient Assistance Foundations

Acthar Gel Patient Assistance Program (via NORD)

  • For uninsured or underinsured patients
  • Income-based eligibility with annual review
  • Requires valid prescription for FDA-approved indication
  • Must be permanent US or Puerto Rico resident
  • Contact: 1-800-459-7599

PAF Co-Pay Relief Program

  • Up to $2,000 annual maximum benefit
  • Available for Medicare and Medicaid patients
  • Requires financial documentation within 30 days
  • 12-month waiting period if forfeited due to non-compliance

Case Management Support

Acthar Patient Support provides dedicated case managers who can:

  • Navigate insurance benefits and PA requirements
  • Coordinate with specialty pharmacies
  • Assist with appeal letter preparation
  • Track authorization status and renewal dates
  • Connect patients with financial assistance programs

Getting Prior Authorization Approved

Step-by-Step PA Process

1. Prescriber Preparation (1-2 days)

  • Gather complete medical records documenting diagnosis
  • Compile detailed history of prior corticosteroid trials
  • Prepare medical necessity letter with clinical justification
  • Collect supporting literature and guidelines

2. PA Submission (Same day)

  • Submit via Aetna provider portal or fax to 1-866-249-6155
  • Include all required forms and supporting documentation
  • Request expedited review if clinically urgent (24-72 hour decision)
  • Confirm receipt and obtain reference number

3. Review Period (Standard: 30-45 days, Expedited: 24-72 hours)

  • Aetna reviews clinical documentation against PA criteria
  • May request additional information or peer-to-peer review
  • Decision communicated to prescriber and patient

4. Approval or Denial

  • If approved: Authorization sent to CVS Specialty Pharmacy
  • If denied: Detailed denial letter with specific reasons provided

Medical Necessity Documentation Checklist

Your prescriber's medical necessity letter should include:

Clinical Information

  • Specific diagnosis with ICD-10 codes
  • Current symptoms and functional limitations
  • Treatment goals and expected outcomes
  • Dosing rationale based on FDA labeling

Prior Therapy Documentation

  • Complete list of previous treatments tried
  • Specific medications, doses, and durations
  • Clinical outcomes and reasons for discontinuation
  • Documentation of corticosteroid failure, intolerance, or contraindications

Evidence-Based Support

  • FDA prescribing information citations
  • Relevant clinical practice guidelines
  • Peer-reviewed literature supporting use
  • Specialist consultation notes if applicable
Clinician Corner: For MS exacerbations, document failed 3-day trial of IV methylprednisolone (≥1000 mg/day). For nephrotic syndrome, provide evidence of corticosteroid contraindications or inadequate response. Include neurologist consultation for infantile spasms in patients <2 years old.

Specialty Pharmacy Coordination

CVS Specialty Pharmacy Process

Benefits Investigation CVS Specialty initiates benefits verification after receiving:

  • Completed referral form from prescriber
  • Patient insurance information (cards front/back)
  • Prescription details with ICD-10 diagnosis codes
  • Prior authorization approval or pending status

Coordination Steps

  1. Case Assignment: Dedicated case manager assigned
  2. PA Support: Assistance with documentation and appeals if needed
  3. Delivery Scheduling: Direct patient contact for delivery coordination
  4. Clinical Support: Injection training and ongoing monitoring
  5. Refill Management: Automatic renewal coordination with prescriber

Patient Portal Access Use CVS Specialty Central to:

  • Track prescription and PA status in real-time
  • Schedule deliveries and manage refills
  • Access educational resources and injection guides
  • Communicate with your care team

Storage and Administration

Proper Handling

  • Acthar Gel requires refrigeration (36-46°F)
  • Allow to reach room temperature before injection
  • Use within 28 days of first puncture
  • Rotate injection sites to prevent tissue damage

Injection Support CVS Specialty provides:

  • Initial injection training via phone or video
  • Printed administration guides
  • Sharps disposal containers
  • 24/7 clinical support hotline

Appeals Process in Michigan

Internal Appeals with Aetna CVS Health

Timeline and Process

  • File within: 180 days of denial (commercial plans) or 60 days (Medicare)
  • Standard review: 30-45 days for decision
  • Expedited appeals: 24-72 hours if urgent medical need
  • Submit to: Aetna Appeals Department via member portal, phone, or mail

Required Documentation

  • Original denial letter and EOB
  • Updated medical necessity letter addressing denial reasons
  • Additional clinical evidence or specialist consultation
  • Patient impact statement (optional but helpful)

Escalation Options

  • Request peer-to-peer review between prescriber and Aetna medical director
  • Submit additional clinical literature or guideline citations
  • Engage Counterforce Health for evidence-backed appeal preparation

External Review Through Michigan DIFS

If internal appeals fail, Michigan law provides additional protection:

Eligibility

  • Must exhaust Aetna's internal appeal process
  • Have received final denial letter
  • Treatment must be for covered condition
  • File within 127 days of final denial

Process

  1. Submit Request: Online at Michigan DIFS website or via paper form
  2. Review Assignment: DIFS assigns to Independent Review Organization (IRO)
  3. Medical Review: Independent physicians review case
  4. Timeline: Standard decisions within 60 days, expedited within 72 hours
  5. Binding Decision: IRO determination is final and enforceable

Contact Information

  • Michigan DIFS: 1-877-999-6442
  • Online external review request forms available
  • Email, fax, or mail submission options
Note: For expedited external appeals, your physician must provide a letter stating that delay would seriously jeopardize your health.

Annual Renewal and Budget Planning

What Changes Each Year

Plan Year Considerations

  • Formulary tier placement may change
  • PA criteria can be updated or modified
  • Copay assistance program terms may be revised
  • Specialty pharmacy networks might be altered

Renewal Checklist

  • Review new plan documents in October-November
  • Confirm Acthar Gel remains covered
  • Check for changes in PA requirements
  • Renew copay assistance programs by January
  • Update financial assistance applications if income changed

Budget Planning Tips

  • Calculate worst-case annual out-of-pocket costs
  • Factor in potential PA denial delays
  • Plan for possible appeals and associated costs
  • Consider HSA/FSA contributions for specialty drug costs

Proactive Renewal Steps

60 Days Before Expiration

  • Contact prescriber to begin renewal PA process
  • Update clinical documentation with current status
  • Renew manufacturer copay assistance enrollment
  • Confirm continued medical necessity

30 Days Before Expiration

  • Submit renewal PA to Aetna CVS Health
  • Schedule follow-up appointments for monitoring
  • Ensure adequate supply during transition period
  • Update emergency contact information

Conversation Scripts

Calling Aetna Member Services

"Hi, I'm calling about prior authorization requirements for Acthar Gel. My member ID is [ID number]. Can you tell me what specific documentation my doctor needs to submit for approval? I'd also like to understand my out-of-pocket costs once it's approved and whether there's a specialty copay maximum on my plan."

Requesting Expedited Review

"My doctor is requesting an expedited prior authorization for Acthar Gel because [brief medical reason]. The standard 30-day review would delay medically necessary treatment. Can you please process this as urgent and provide a reference number for tracking?"

Specialty Pharmacy Coordination

"I'm starting Acthar Gel and need to coordinate delivery and injection training. My prescription should be approved by [date]. Can you assign a case manager to help with benefits verification and delivery scheduling? I'll also need information about your clinical support services."

Appeal Preparation

"I'm appealing the denial of Acthar Gel. The denial letter states [specific reason]. My doctor has additional clinical information showing why this medication is medically necessary after failing corticosteroids. Can you tell me exactly what documentation you need and the best way to submit it for fastest review?"

FAQ

How long does Aetna CVS Health PA take in Michigan? Standard prior authorization reviews take 30-45 days. Expedited reviews for urgent medical needs are completed within 24-72 hours. Submit complete documentation upfront to avoid delays.

What if Acthar Gel is non-formulary on my plan? You can request a formulary exception with medical necessity documentation. Your prescriber must demonstrate that formulary alternatives are inappropriate or have failed. The appeals process applies if initially denied.

Can I request an expedited appeal in Michigan? Yes, both Aetna internal appeals and Michigan DIFS external reviews offer expedited processes. Your physician must provide documentation that delay would seriously jeopardize your health.

Does step therapy apply if I failed corticosteroids outside Michigan? Yes, documented corticosteroid failures from any location count toward step therapy requirements, provided you have complete medical records showing specific medications, doses, durations, and outcomes.

How much will I pay out-of-pocket with Aetna CVS Health? Costs vary by plan design. Specialty tier coinsurance is typically 25-50% of drug cost, but copay assistance can reduce this to $0-50/month for eligible patients with commercial insurance.

What happens if my PA expires? You'll need renewal authorization before your current approval ends. Start the renewal process 60 days early to ensure continuous coverage. CVS Specialty can help coordinate timing.

Can I appeal based on cost grounds alone? Appeals must demonstrate medical necessity, not just cost concerns. However, you can request tier exceptions or coverage of lower-cost alternatives if clinically appropriate.

What if I switch from commercial insurance to Medicare? You'll lose eligibility for manufacturer copay assistance but may qualify for patient assistance foundations. Contact Acthar Patient Support to explore Medicare-compatible financial assistance options.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by providing evidence-backed documentation that addresses payer-specific requirements. Our platform streamlines the prior authorization and appeals process for complex specialty medications like Acthar Gel.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage and requirements vary by individual plan. Always consult with your healthcare provider and insurance company for personalized guidance. For questions about Michigan insurance regulations, contact the Department of Insurance and Financial Services at 1-877-999-6442.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.