By Counterforce Health Team in Strensiq (asfotase alfa) —

The Complete Guide to Getting Strensiq (Asfotase Alfa) Covered by Aetna CVS Health in Georgia: Prior Authorization, Appeals & Templates

Answer Box: Fast Track to Strensiq Coverage

To get Strensiq (asfotase alfa) covered by Aetna CVS Health in Georgia, you need prior authorization with specific documentation: confirmed hypophosphatasia diagnosis (genetic testing or low alkaline phosphatase + elevated substrates), radiographic evidence, and proof of pediatric-onset disease. Submit the 2024 Aetna Strensiq Precertification Form to fax 1-888-267-3277 with all required lab results and clinical notes. Standard review takes 15 business days; expedited reviews 72 hours. If denied, you have 180 days to appeal, then external review through Georgia Department of Insurance within 60 days.

Start today: Download the PA form and gather genetic testing, alkaline phosphatase levels, and radiographic imaging.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria for Approval
  4. Required Documentation Packet
  5. Submission Process
  6. CVS Specialty Pharmacy Coordination
  7. Appeals Playbook for Georgia
  8. Common Denial Reasons & Solutions
  9. Cost Assistance Programs
  10. FAQ

Who Should Use This Guide

This guide is for patients with hypophosphatasia (HPP) and their healthcare teams seeking Strensiq coverage through Aetna CVS Health in Georgia. Use this if you:

  • Have confirmed or suspected perinatal/infantile-onset or juvenile-onset HPP
  • Need to start Strensiq therapy or transfer from another insurer
  • Received a denial and need to file an appeal
  • Want to avoid common prior authorization pitfalls

Expected outcome: With proper documentation, approval rates for medically appropriate Strensiq requests exceed 80%. The key is meeting Aetna's strict diagnostic criteria and submitting complete clinical evidence.

Member & Plan Basics

Coverage Verification

Before starting the prior authorization process:

  • Confirm active Aetna coverage through the member portal or by calling the number on your insurance card
  • Verify specialty drug benefits - most Aetna plans require prior authorization for medications over $600/month
  • Check your deductible status - high-deductible plans may require meeting the deductible first
  • Identify your specialty pharmacy network - Aetna typically uses CVS Specialty or contracted partners

Plan Types in Georgia

  • Commercial plans: Standard PA process through Aetna
  • Medicaid (PeachCare): May have additional state-specific requirements
  • Medicare Part D: Federal appeal rights apply with shorter timelines

Clinical Criteria for Approval

Aetna's Medical Necessity Requirements

Aetna covers Strensiq only for patients meeting all of these criteria:

1. Confirmed HPP Diagnosis Must have clinical signs/symptoms of hypophosphatasia AND either:

  • Genetic confirmation: Known pathogenic ALPL gene mutation, OR
  • Biochemical confirmation: ALL of the following:
    • Serum alkaline phosphatase below age/gender reference range
    • Elevated TNSALP substrate (serum PLP, urine PEA, or plasma PPi)
    • Radiographic skeletal abnormalities consistent with HPP

2. Disease Onset Requirements

  • Perinatal/infantile-onset or juvenile-onset HPP only
  • If patient is ≥18 years: documentation proving symptom onset before age 18

3. Dosing Limits

  • Perinatal/infantile-onset: maximum 9 mg/kg/week
  • Juvenile-onset: maximum 6 mg/kg/week

4. Prescriber Requirements Must be prescribed by appropriate specialist (endocrinologist, geneticist, or metabolic specialist)

Note: Adult-onset HPP and off-label uses are considered experimental and not covered by Aetna.

Required Documentation Packet

Core Clinical Documentation

Laboratory Results:

  • Serum alkaline phosphatase with age/gender reference ranges
  • ALPL gene mutation analysis (if available)
  • Elevated TNSALP substrates (PLP, PEA, or PPi)
  • Supporting labs (calcium, phosphate, vitamin D)

Imaging Studies:

  • Radiographs showing skeletal abnormalities
  • Growth charts (for pediatric patients)
  • Bone density studies (if performed)

Clinical Notes:

  • Initial consultation establishing HPP diagnosis
  • Documentation of symptom onset timing
  • Physical examination findings
  • Treatment history and response to supportive care

Medical Necessity Letter Template

Your prescribing physician should include these elements:

[Patient Name, DOB, Insurance ID]

Dear Aetna Medical Review Department,

I am requesting prior authorization for Strensiq (asfotase alfa) for my patient [Name], who has confirmed [perinatal/infantile/juvenile]-onset hypophosphatasia.

DIAGNOSIS: Hypophosphatasia confirmed by:
- [Genetic testing results OR biochemical criteria]
- Clinical presentation: [symptom onset, current manifestations]
- Radiographic findings: [specific abnormalities]

MEDICAL NECESSITY: Strensiq is FDA-approved and the only disease-modifying therapy for pediatric-onset HPP. This patient meets all criteria in Aetna's medical policy. Without treatment, the patient faces [specific risks: bone deformity, fractures, respiratory compromise].

REQUESTED DOSING: [X] mg/kg/week, within FDA-approved limits

Please find attached: lab results, genetic testing, imaging studies, and clinical documentation supporting this request.

Sincerely,
[Physician Name, Credentials]
[Contact Information]

Submission Process

Step-by-Step Submission

1. Download Current Forms

2. Complete All Required Fields

  • Patient demographics and insurance information
  • Diagnosis codes (E83.30-E83.32, E83.39)
  • Prescriber information and specialty
  • Dosing details with weight-based calculations
  • Clinical justification summary

3. Attach Supporting Documentation

  • Medical necessity letter
  • Laboratory results with reference ranges
  • Genetic testing report (if available)
  • Radiographic studies
  • Relevant clinical notes

4. Submit via Approved Channels

  • Fax: 1-888-267-3277
  • Phone inquiries: 1-866-752-7021
  • Provider portal: Availity or Aetna provider site

5. Track Submission

  • Request confirmation number
  • Note submission date for timeline tracking
  • Follow up if no acknowledgment within 5 business days

Processing Timelines

  • Standard review: Up to 15 business days
  • Expedited review: Within 72 hours (requires urgent medical justification)
  • Acknowledgment: Within 5 business days of receipt

CVS Specialty Pharmacy Coordination

Preferred Pharmacy Network

Strensiq is available through limited distribution. In Georgia:

  • CVS Specialty is often preferred for Aetna members
  • Alternative networks may include Accredo or health system specialty pharmacies
  • Confirm network status with your insurance before transferring prescriptions

Transfer Process

  1. Verify insurance coverage at new pharmacy
  2. Contact receiving pharmacy to initiate transfer
  3. Provide current pharmacy information and prescription details
  4. Coordinate with prescriber for any required new documentation
  5. Ensure continuous supply during transition
Tip: Start the transfer process early—specialty pharmacy transfers can take 3-5 business days to complete.

Appeals Playbook for Georgia

Internal Appeal Process

Timeline: 180 days from denial letter date to submit appeal

Required Documents:

  • Original denial letter
  • Member ID and claim information
  • Updated medical necessity letter addressing denial reasons
  • Additional clinical evidence
  • Peer-reviewed literature supporting treatment

Submission Methods:

  • Aetna provider portal (preferred)
  • Certified mail with tracking
  • Fax with delivery confirmation

External Review Rights in Georgia

If internal appeals are denied, Georgia residents have strong external review rights:

Timeline: 60 days from final internal denial to request external review

Process:

  1. Submit application to Georgia Department of Insurance
  2. Call Consumer Services: 1-800-656-2298
  3. Complete external review form (available on DOI website)
  4. Independent physician review by specialists in same field
  5. Binding decision within 30 business days

Contact Information:

  • Georgia Department of Insurance
  • Consumer Services Division
  • Website: (verify current contact through Georgia DOI)
Important: External review is free for consumers and decisions are binding on insurers.

Counterforce Health helps patients and clinicians navigate complex prior authorization and appeal processes by turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to create point-by-point rebuttals aligned with payer-specific requirements, significantly improving approval rates for specialty medications like Strensiq.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Insufficient genetic evidence Provide ALPL mutation testing or complete biochemical workup Genetic lab report OR (low ALP + elevated substrates + imaging)
Adult-onset HPP Document pediatric symptom onset Childhood medical records, growth charts, early imaging
Experimental/investigational Cite FDA approval and medical policy FDA prescribing information, Aetna medical policy reference
Dosing exceeds guidelines Justify higher dosing or reduce to approved limits Clinical response data, specialist consultation notes
Missing radiographic evidence Submit bone imaging showing HPP changes X-rays, bone scans with radiologist interpretation

Success Strategies

  • Address denial reasons directly in appeal letters
  • Include peer-reviewed references supporting treatment
  • Request peer-to-peer review for complex cases
  • Document treatment urgency for expedited processing
  • Maintain detailed records of all communications

Cost Assistance Programs

Manufacturer Support

  • Alexion Access Navigator: Patient assistance program
  • Copay assistance: May reduce out-of-pocket costs
  • Prior authorization support: Free assistance with PA submissions

Foundation Grants

  • National Organization for Rare Disorders (NORD): Patient assistance
  • HealthWell Foundation: Copay assistance for qualifying patients
  • Patient Advocate Foundation: Financial and insurance navigation support

State Resources

  • Georgia Department of Insurance: Consumer assistance with appeals
  • Georgians for a Healthy Future: Nonprofit consumer advocacy

FAQ

Q: How long does Aetna prior authorization take for Strensiq in Georgia? A: Standard review takes up to 15 business days. Expedited reviews for urgent cases are completed within 72 hours.

Q: What if Strensiq is not on my Aetna formulary? A: File a formulary exception request with medical necessity documentation. Strensiq has no therapeutic alternatives, strengthening exception requests.

Q: Can I appeal if I don't have genetic testing? A: Yes. Aetna accepts biochemical confirmation (low alkaline phosphatase + elevated substrates + radiographic evidence) if genetic testing is unavailable.

Q: Does step therapy apply to Strensiq? A: No. Strensiq is the only FDA-approved treatment for HPP, so step therapy requirements don't apply.

Q: What happens if I miss the appeal deadline? A: Georgia allows 180 days for internal appeals and 60 days for external review. Missing deadlines typically voids appeal rights, so act quickly.

Q: Can I get expedited review for my child? A: Yes, if you can document that standard processing timelines would seriously jeopardize your child's health or ability to regain maximum function.

From Our Advocates

We've seen many families successfully obtain Strensiq coverage after initial denials by focusing on comprehensive documentation. One key insight: include pediatric growth charts and early medical records even for adult patients—this proves childhood onset and strengthens the medical necessity case. The combination of genetic confirmation and clear radiographic evidence typically results in approval within the first review cycle.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and requirements may change. Always consult with your healthcare provider and verify current requirements with Aetna and Georgia regulatory authorities.

For additional support with complex prior authorization cases, Counterforce Health provides specialized assistance in developing evidence-based appeals that align with payer-specific criteria and significantly improve approval rates for specialty medications.

Sources & Further Reading

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