By Counterforce Health Team in Epidiolex (cannabidiol) —

The Requirements Checklist to Get Epidiolex (Cannabidiol) Covered by Aetna (CVS Health) in Michigan

Answer Box: Get Epidiolex Covered by Aetna in Michigan

Aetna (CVS Health) requires prior authorization for Epidiolex with no step therapy for FDA-approved seizure indications (LGS, Dravet, TSC). Submit via the Aetna provider portal with confirmed diagnosis, seizure logs, prior medication history, current liver function tests, and neurologist letter. Standard decisions take 7 days; denials can be appealed internally (67-75% success rate) then through Michigan DIFS external review within 4 months. Start today: Verify your plan's specialty pharmacy network and gather baseline seizure frequency data from the past 4 weeks.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria
  4. Coding & Documentation
  5. Submission Process
  6. Specialty Pharmacy Requirements
  7. After Submission
  8. Common Denial Prevention Tips
  9. Appeals Process in Michigan
  10. Printable Checklist

Who Should Use This Checklist

This guide is for Michigan patients with Lennox-Gastaut syndrome (LGS), Dravet syndrome, or tuberous sclerosis complex (TSC) who need Epidiolex coverage through Aetna (CVS Health) plans. It's also valuable for neurologists, epileptologists, and clinic staff managing prior authorization requests.

Expected outcome: With proper documentation, Aetna approves Epidiolex for FDA-labeled indications in approximately 7 days. Internal appeals have a 67-75% success rate when clinical criteria are met, rising to 89% with optimized strategies.

Member & Plan Basics

✓ Verify Active Coverage

  • Current Aetna member ID and policy effective dates
  • Plan type: Commercial, Exchange (ACA), Medicaid (Aetna Better Health), or Medicare Advantage
  • Specialty pharmacy benefit active (most Aetna plans route Epidiolex through CVS Specialty)

✓ Authorization Requirements

  • Prior authorization required: Yes, for all Epidiolex prescriptions under Aetna's 2024 specialty policy
  • Step therapy: None for LGS, Dravet, or TSC (may apply to some Medicaid products)
  • Quantity limits: Weight-based dosing within FDA limits (up to 20 mg/kg/day)
Note: Aetna's precertification list confirms Epidiolex requires PA under specialty pharmacy clinical policies.

Clinical Criteria

✓ FDA-Approved Indications Only

Must have ONE of these diagnoses:

  • Lennox-Gastaut syndrome with seizures (ICD-10: G40.811-G40.814)
  • Dravet syndrome (ICD-10: G40.83x series)
  • Tuberous sclerosis complex with seizures (ICD-10: Q85.1 + seizure code)

Age requirement:

  • Patient ≥ 1 year old (per FDA labeling)

✓ Baseline Clinical Documentation

  • Confirmed diagnosis in neurology notes with syndrome-specific features
  • Seizure frequency baseline over past 4+ weeks (seizure diary preferred)
  • Current weight for dose calculation
  • Neurologist involvement (prescriber or consultant)

✓ Prior Therapy Documentation

While Aetna doesn't require formal step therapy for LGS/Dravet/TSC, document:

  • Previous antiseizure medications tried (names, doses, duration)
  • Outcomes: inadequate control, intolerance, or contraindications
  • Current regimen and persistent seizure burden

Coding & Documentation

✓ ICD-10 Codes

Use syndrome-specific codes when available:

Condition Primary ICD-10 Notes
Lennox-Gastaut syndrome G40.811-G40.814 Specify intractable status and status epilepticus
Dravet syndrome G40.83x Payer policies reference G40.83* series
TSC with seizures Q85.1 + G40.x Combine TSC diagnosis with appropriate seizure code

✓ Prescription Details

  • NDC-based billing (oral solution, not J-code)
  • Strength: 100 mg/mL oral solution
  • Dose calculation: Document mg/kg/day within FDA limits
  • Quantity: Based on weight and prescribed dose

Documentation Packet

✓ Provider Requirements

Medical necessity letter must include:

  • Patient demographics and member ID
  • Confirmed diagnosis with ICD-10 code
  • Seizure history: type, frequency, functional impact
  • Prior medications: specific agents, doses, outcomes
  • Clinical rationale: why Epidiolex is medically necessary
  • Dose justification: starting dose and titration plan
  • Monitoring plan: seizure tracking and lab schedule

✓ Required Attachments

  • Seizure diary or frequency documentation (past 4+ weeks)
  • Current medication list with doses and start dates
  • Baseline liver function tests (ALT, AST, total bilirubin)
  • Prior therapy documentation (prescription history or clinic notes)
  • Diagnostic reports (EEG, MRI, genetic testing if relevant)
Clinician Tip: Use the manufacturer's sample letter template as a starting point, then customize with Aetna-specific language.

Submission Process

✓ Correct Forms and Portals

  • Submit via: Aetna provider portal (Availity/Novologix for specialty drugs)
  • Phone option: 1-866-600-7800 (varies by plan)
  • Reference: Epidiolex policy 2609-A SGM P2024

✓ Common Rejection Prevention

Ensure these fields are complete:

  • Patient weight and dose calculation shown
  • Prescriber NPI and specialty (neurology preferred)
  • Diagnosis matches FDA-approved indication exactly
  • All required attachments included with submission

Specialty Pharmacy Requirements

✓ CVS Specialty Enrollment

For Aetna members, Epidiolex typically routes through CVS Specialty:

  • Enrollment: Use EPIDIOLEX Engage Hub or direct CVS Specialty referral
  • Provider contact: 1-800-237-2767 for CVS Specialty
  • Prescription: E-prescribe or fax to 1-800-323-2445

✓ Transfer from Current Pharmacy

  • Contact CVS Specialty to initiate transfer
  • Prescriber resends prescription (Epidiolex requires specialty handling)
  • Verify Michigan shipping eligibility (1-2 day delivery standard)

After Submission

✓ Track Your Request

  • Record confirmation number from portal/phone submission
  • Standard timeline: 7 days for PA decision
  • Status checks: Via Aetna provider portal or member services
  • Approval length: Typically 12 months with annual renewal

✓ What to Document

  • Submission date and method
  • Reference/confirmation numbers
  • Contact person if submitted by phone
  • Any additional information requested

Common Denial Prevention Tips

Five Pitfalls to Avoid:

  1. ❌ Off-label use: Aetna considers non-FDA indications "experimental/investigational" ✅ Fix: Clearly state "seizures associated with [LGS/Dravet/TSC]" matching FDA language
  2. ❌ Missing liver monitoring: Hepatotoxicity risk requires baseline labs ✅ Fix: Include recent LFTs (within 30 days) and monitoring plan
  3. ❌ Incomplete seizure documentation: Vague "frequent seizures" descriptions ✅ Fix: Provide specific frequency (e.g., "15 drop attacks per week") with dates
  4. ❌ Wrong dose calculation: Exceeding FDA mg/kg/day limits ✅ Fix: Show weight-based calculation within 20 mg/kg/day maximum
  5. ❌ Generic diagnosis codes: Using broad epilepsy codes instead of syndrome-specific ✅ Fix: Use G40.81x for LGS, G40.83x for Dravet, Q85.1+seizure code for TSC

Appeals Process in Michigan

Internal Appeal (First Level)

  • Deadline: 180 days from denial notice
  • Timeline: 30 calendar days for decision
  • How to file: Aetna provider portal or member services
  • Success rate: 67-75% for medical necessity

Michigan DIFS External Review

If internal appeal fails:

  • Deadline: 4 months from Aetna's final denial
  • Timeline: ~21-30 days (IRO review + Director decision)
  • How to file: DIFS online form or paper submission
  • Contact: 877-999-6442 (DIFS consumer assistance)
Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform ingests denial letters and plan policies, then drafts point-by-point rebuttals aligned to the plan's own rules, helping patients get medications like Epidiolex approved faster.

Printable Checklist

Before Submission:

  • Confirmed FDA indication (LGS/Dravet/TSC)
  • Patient ≥ 1 year old
  • Current weight documented
  • Baseline LFTs within 30 days
  • 4+ weeks seizure frequency data
  • Prior medication history with outcomes
  • Neurologist letter with dose justification
  • Correct ICD-10 codes selected

Submission Day:

  • Aetna provider portal login working
  • All attachments in PDF format
  • Confirmation number recorded
  • Follow-up reminder set for 5-7 days

If Denied:

  • Request specific denial reason
  • Internal appeal filed within 180 days
  • Additional evidence gathered
  • DIFS external review option noted (4-month deadline)

Frequently Asked Questions

Q: How long does Aetna PA take for Epidiolex in Michigan? A: Standard prior authorization decisions are made within 7 days. Expedited reviews (for urgent cases) are available within 72 hours.

Q: Does Aetna require step therapy before approving Epidiolex? A: No formal step therapy for FDA-approved indications (LGS, Dravet, TSC), but document prior antiseizure medication trials for medical necessity.

Q: What if my neurologist isn't the prescriber? A: Aetna prefers neurologist or epileptologist prescribers. If your primary care doctor prescribes, include neurologist consultation notes.

Q: Can I appeal if Epidiolex is non-formulary? A: Yes, request formulary exception with medical necessity documentation. Non-formulary doesn't prevent coverage if medically necessary.

Q: What counts as baseline seizure documentation? A: Seizure diary over 4+ weeks showing type, frequency, and duration. Clinic notes with specific counts also acceptable.

This guide provides general information about insurance processes and should not replace professional medical or legal advice. For personalized assistance, consult your healthcare provider or contact Michigan DIFS at 877-999-6442.

Sources & Further Reading:

For additional support with complex appeals, Counterforce Health helps patients and clinicians turn insurance denials into successful approvals through evidence-backed appeal strategies.

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