By Counterforce Health Team in Taltz (ixekizumab) —

The Requirements Checklist to Get Taltz (ixekizumab) Covered by Aetna (CVS Health) in Illinois

Quick Answer: Getting Taltz (ixekizumab) Covered by Aetna (CVS Health) in Illinois

Who's eligible: Illinois residents with Aetna (CVS Health) coverage diagnosed with moderate-to-severe plaque psoriasis, psoriatic arthritis, or ankylosing spondylitis who meet step therapy requirements.

Fastest path: Submit Aetna's Taltz precertification form (GR-69231) plus Illinois PA form with documented trials/failures of conventional therapies and TB screening. Use CVS Specialty enrollment for dispensing.

First step today: Download the Taltz precertification form and gather documentation of prior therapy failures. Illinois law prohibits step therapy for formulary drugs on fully insured plans as of January 2025.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding and Billing Information
  5. Documentation Packet Requirements
  6. Submission Process
  7. CVS Specialty Pharmacy Setup
  8. After Submission: Tracking Your Request
  9. Common Denial Prevention Tips
  10. Appeals Process in Illinois
  11. Cost Savings and Support
  12. Printable Quick Reference

Who Should Use This Checklist

This guide is designed for Illinois patients and their healthcare providers seeking Aetna (CVS Health) coverage for Taltz (ixekizumab) for:

  • Moderate-to-severe plaque psoriasis in adults and pediatric patients ≥6 years
  • Active psoriatic arthritis
  • Ankylosing spondylitis
  • Non-radiographic axial spondyloarthritis

Expected outcome: With proper documentation and adherence to this checklist, most medically appropriate Taltz requests receive approval within 30-45 days. Illinois residents have additional protections under new 2025 state laws that prohibit step therapy for formulary medications on fully insured plans.

Member & Plan Basics

Verify Active Coverage

Before starting, confirm:

  • Active Aetna (CVS Health) membership with current ID card
  • Plan type: Commercial, Medicare Advantage, or Medicaid (Aetna Better Health)
  • Formulary status: Check if Taltz is on your plan's drug list
  • Specialty pharmacy requirement: Most Aetna plans require CVS Specialty for biologics

Illinois Plan Protections (2025)

Important: Illinois law effective January 1, 2025, prohibits step therapy requirements for drugs on the formulary for fully insured plans. This doesn't apply to self-insured (ERISA) employer plans.

Note: Check your ID card or contact HR to determine if your plan is fully insured or self-insured. Fully insured plans cannot require "fail first" protocols for formulary medications.

Clinical Criteria Requirements

FDA-Approved Indications

Taltz must be prescribed for an approved indication with proper ICD-10 coding:

Condition ICD-10 Code Key Requirements
Plaque psoriasis L40.0 Moderate-to-severe disease, BSA >3% or special sites
Psoriatic arthritis L40.5, M07.0-M07.3 Active disease with joint involvement
Ankylosing spondylitis M45.0-M45.9 Confirmed diagnosis with imaging/labs

Step Therapy Documentation

For self-insured plans (ERISA), document trials and failures of:

For Psoriasis:

  • High-potency topical corticosteroids
  • Phototherapy (NB-UVB or PUVA) OR contraindication
  • At least one systemic agent: methotrexate, cyclosporine, or acitretin

For Psoriatic Arthritis/Ankylosing Spondylitis:

  • At least one conventional DMARD: methotrexate, sulfasalazine, leflunomide, or hydroxychloroquine
  • Document duration (minimum 3 months unless intolerant)
  • Clear reasons for discontinuation

Safety Requirements

Mandatory TB screening within 6 months:

  • PPD or IGRA test results
  • Chest X-ray
  • Document no active TB or latent TB treatment completion

Coding and Billing Information

HCPCS/J-Codes

  • Primary: J3590 (Unclassified biologics)
  • Alternative: J3490 (Unclassified drugs) - if required by specific plan
  • NDC: Include specific NDC number in claim narrative

Billing Considerations

Most Aetna plans cover Taltz under the pharmacy benefit through CVS Specialty, not as a buy-and-bill medical benefit. Confirm benefit type before ordering.

Documentation Packet Requirements

Provider Note Elements

Your clinical documentation must include:

  1. Diagnosis confirmation with ICD-10 code
  2. Disease severity assessment:
    • % Body Surface Area (BSA) for psoriasis
    • PASI score if available
    • Functional impact on daily activities
  3. Complete prior therapy history with:
    • Drug names and doses
    • Duration of each trial
    • Specific reasons for discontinuation
    • Dates of treatment periods
  4. TB screening results with dates
  5. Treatment plan with Taltz dosing schedule

Letter of Medical Necessity Components

Your LMN should address Aetna's specific criteria:

  1. Patient demographics and Aetna member ID
  2. Prescriber credentials and NPI
  3. Clinical rationale mapping to Aetna's Taltz policy
  4. Step therapy compliance or Illinois law exemption
  5. Safety confirmation (no active infections, TB screening complete)
  6. Dosing justification per FDA labeling

Required Attachments

  • Clinic notes supporting diagnosis and severity
  • Lab results (TB screening, relevant monitoring)
  • Prior therapy documentation
  • Photos of affected areas (for psoriasis)
  • Insurance card copies (front and back)

Submission Process

Required Forms

Primary Form: Taltz Injectable Medication Precertification Request (GR-69231)

Illinois-Specific: Illinois Prior Authorization Request Form

Submission Channels

Plan Type Phone Fax Portal
Commercial 1-855-240-0535 1-877-269-9916 Availity/Novologix
Medicare Advantage 1-855-240-0535 1-844-268-7263 Availity
Illinois Medicaid 1-866-329-4701 1-877-779-5234 Plan-specific

Timeline Expectations

  • Standard PA: 15-30 business days
  • Expedited PA: 24-72 hours (with medical urgency)
  • Illinois external review: 45 days maximum

CVS Specialty Pharmacy Setup

Enrollment Process

  1. Provider completes CVS Specialty Dermatology/Psoriasis Enrollment Form
  2. Submit via:
    • Fax: 1-800-323-2445
    • Phone: 1-800-237-2767
    • ePrescribe to "CVS Specialty Pharmacy"

Patient Setup

Once enrolled, patients can:

  • Create online account at CVS Specialty
  • Track prescriptions and delivery
  • Coordinate with CareTeam for refills
Tip: CVS Specialty can handle PA submissions on behalf of prescribers when authorized on the enrollment form.

After Submission: Tracking Your Request

Confirmation Steps

  1. Record confirmation number from submission
  2. Set calendar reminder for follow-up (14 days)
  3. Monitor for requests for additional information
  4. Document all communications with date/time stamps

Status Check Schedule

  • Week 1: Confirm receipt with Aetna
  • Week 2: Check for any additional information requests
  • Week 3-4: Follow up if no decision received
  • After 30 days: Consider expedited review or appeal

Common Denial Prevention Tips

Top 5 Pitfalls to Avoid

  1. Incomplete step therapy documentation
    • Fix: Provide detailed trial history with specific dates and outcomes
  2. Missing TB screening
    • Fix: Include all TB test results with dates within 6 months
  3. Insufficient severity documentation
    • Fix: Include BSA percentage, PASI scores, and functional impact
  4. Wrong forms or outdated versions
    • Fix: Always download current forms from official Aetna provider portal
  5. Concurrent biologic therapy
    • Fix: Clearly state Taltz will not be used with other biologics
From our advocates: "We've seen many Illinois denials overturned simply by citing the new state step therapy prohibition for formulary drugs. Always check if the patient's plan is fully insured and reference Illinois law when applicable."

Appeals Process in Illinois

Internal Appeal (First Level)

  • Deadline: 180 days from denial date
  • Timeline: 30 days for standard, 72 hours for expedited
  • Submit to: Aetna appeals department per denial letter

External Review (Illinois DOI)

If internal appeal fails:

Required for External Review

  • Copy of Aetna's final denial letter
  • External Review Request Form
  • Clinical documentation supporting medical necessity
  • Physician urgency certification (if expedited)

Cost Savings and Support

Manufacturer Support

  • Taltz Together Savings Program: Up to $25/month copay for eligible patients
  • Enrollment: Through Taltz.com or 1-844-TALTZ-1
  • Eligibility: Commercial insurance required (not Medicare/Medicaid)

Additional Resources

  • Illinois Department of Insurance Consumer Helpline: 1-877-527-9431
  • Illinois Attorney General Health Care Helpline: 1-877-305-5145
  • Patient advocacy organizations: Local legal aid or Citizen Action/Illinois

Printable Quick Reference

✅ Pre-Submission Checklist

Patient Information:

  • Active Aetna (CVS Health) ID card
  • Plan type confirmed (fully insured vs. self-insured)
  • Contact information current

Clinical Documentation:

  • Diagnosis with ICD-10 code
  • Disease severity assessment
  • Complete prior therapy history
  • TB screening results (within 6 months)
  • Provider notes and attachments

Forms and Submission:

  • Current Taltz precertification form (GR-69231)
  • Illinois PA form (if required)
  • CVS Specialty enrollment form
  • Letter of medical necessity
  • Submission method confirmed

Follow-up Plan:

  • Confirmation number recorded
  • Calendar reminders set
  • Contact information for status checks

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements by analyzing denial letters, plan policies, and clinical notes to create compelling appeals that align with each payer's specific criteria.

For complex cases or repeated denials, consider working with advocacy services like Counterforce Health that specialize in insurance appeals and can help strengthen your documentation to meet Aetna's specific requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with healthcare providers and insurance representatives for guidance specific to individual situations. Coverage policies and requirements may change; verify current information with official sources.

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