Topic

Aetna (CVS Health)

A collection of 137 issues

Myths vs. Facts: Getting Cosentyx (Secukinumab) Covered by Aetna (CVS Health) in California

Answer Box: Getting Cosentyx Covered by Aetna (CVS Health) in California Myth: If your doctor prescribes Cosentyx, Aetna must cover it. Fact: Aetna requires prior authorization, step therapy (trying preferred biologics first), and documented TB screening. Success depends on proper documentation of disease severity and prior treatment failures. Fastest path

How to Get Gilenya (Fingolimod) Covered by Aetna CVS Health in Washington: 2025 Prior Authorization Guide

Answer Box: Quick Path to Coverage Aetna CVS Health requires prior authorization for Gilenya (fingolimod) in Washington, with mandatory step therapy through generic fingolimod first. Your neurologist must document relapsing MS diagnosis, submit baseline EKG and monitoring plan, and provide evidence of generic failure/intolerance for brand approval. If denied,

Getting Naglazyme (Galsulfase) Covered by Aetna in Pennsylvania: Coding, Appeals, and Authorization Guide

Quick Answer: Getting Naglazyme Covered by Aetna in Pennsylvania Naglazyme (galsulfase) for MPS VI requires prior authorization from Aetna with specific documentation: confirmed diagnosis via enzyme assay or genetic testing, baseline functional assessments (like six-minute walk tests), and specialist involvement. Bill using HCPCS J1458 under the medical benefit at 1

How to Get Elelyso (Taliglucerase Alfa) Covered by Aetna CVS Health in Illinois: Complete Guide with Forms, Timelines, and Appeal Scripts

Answer Box: Quick Path to Elelyso Coverage Elelyso (taliglucerase alfa) requires prior authorization from Aetna CVS Health in Illinois. Submit your PA request at least two weeks in advance via the Availity provider portal with complete Gaucher disease Type 1 documentation. Good news: Illinois banned step therapy for specialty medications

How to Get Dojolvi (Triheptanoin) Covered by Aetna CVS Health in Texas: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Dojolvi Covered by Aetna CVS Health in Texas Dojolvi (triheptanoin) requires prior authorization from Aetna CVS Health and is not on the 2024 formulary, requiring a formulary exception. Essential requirements include genetic/biochemical LC-FAOD confirmation, specialist documentation, and proof that dietary management alone is inadequate. First step

How to Get Vitrakvi (Larotrectinib) Covered by Aetna CVS Health in Texas: Complete Coverage and Appeal Guide

Answer Box: Getting Vitrakvi Covered by Aetna CVS Health in Texas Vitrakvi (larotrectinib) requires prior authorization with Aetna CVS Health in Texas and documentation of a positive NTRK gene fusion test. The fastest path to approval: (1) Ensure your oncologist has your NTRK fusion test results ready, (2) Submit the

How to Get Ibrance (palbociclib) Covered by Aetna CVS Health in California: Complete Prior Authorization and Appeals Guide

Quick Answer: To get Ibrance (palbociclib) covered by Aetna CVS Health in California, you need prior authorization showing HR-positive, HER2-negative advanced breast cancer diagnosis with proper documentation. Submit through CVS Specialty Pharmacy (1-866-814-5506) with pathology reports and ICD-10 codes C50.- and Z17.411. If denied, file internal appeal within

How to Get Firazyr (Icatibant) Covered by Aetna CVS Health in North Carolina: Appeals, Forms & Cost-Saving Tips

Answer Box: Getting Firazyr Covered by Aetna CVS Health in North Carolina Firazyr (icatibant) requires prior authorization from Aetna CVS Health and is excluded from many standard formularies. To get coverage in North Carolina: (1) Have your HAE specialist submit a prior authorization with confirmed HAE diagnosis and lab results,

How to Get Evrysdi (Risdiplam) Covered by Aetna in Ohio: Appeal Guide with Forms and Timelines

Answer Box: Getting Evrysdi Covered by Aetna in Ohio Fastest path to approval: Submit genetic testing documentation confirming biallelic SMN1 mutations, clinical SMA diagnosis, baseline motor assessments, and prior therapy history to Aetna's prior authorization process. If denied, file an internal appeal within 180 days, then request external

How to Get Amondys 45 (Casimersen) Covered by Aetna CVS Health in Texas: Complete Appeal Guide with Templates

Answer Box: Getting Amondys 45 Covered by Aetna CVS Health in Texas Aetna CVS Health requires prior authorization for Amondys 45 (casimersen) with strict genetic and clinical documentation. The fastest path to approval: 1. Gather genetic testing confirming DMD with exon 45 amenable mutation 2. Submit Aetna's precertification