By Counterforce Health Team in Filsuvez (birch triterpenes topical gel) —

Work With Your Doctor to Get Filsuvez Covered by Aetna CVS Health in Michigan: Complete Prior Authorization Guide

Quick Answer: Your Path to Filsuvez Coverage

Getting Filsuvez (birch triterpenes topical gel) covered by Aetna CVS Health in Michigan requires prior authorization with genetic confirmation of junctional or dystrophic epidermolysis bullosa, documented wound characteristics, and evidence of standard care attempts. Your doctor submits through Aetna's Availity portal or fax (1-888-267-3277). First step today: Schedule a visit to review your EB subtype confirmation, wound documentation, and prior treatments—this partnership approach significantly improves approval odds.

Table of Contents

Set Your Goal: Understanding Approval Requirements

Filsuvez requires prior authorization from Aetna CVS Health for both commercial and Medicare Advantage plans. Success depends on meeting specific clinical criteria and providing complete documentation through your healthcare provider.

What Aetna CVS Health Requires

Your doctor must demonstrate that you meet FDA-approved criteria:

  • Age: 6 months or older
  • Diagnosis: Genetically confirmed junctional or dystrophic epidermolysis bullosa (not EB simplex or Kindler syndrome)
  • Wound characteristics: Partial-thickness wounds, 10-50 cm², present for at least 3 weeks
  • Infection status: Wounds must be free from active infection
  • Provider involvement: Treatment supervised by an EB specialist or experienced dermatologist
Note: Filsuvez is not approved for recessive dystrophic EB patients also receiving Vyjuvek gene therapy.

Your Role in the Partnership

While your doctor handles the technical submission, your preparation and advocacy are crucial. You'll gather documentation, provide detailed treatment history, and support the medical necessity case. This collaborative approach addresses the reality that over 95% of Aetna prior authorizations are approved within 24 hours when documentation is complete and accurate.

Prepare for Your Provider Visit

Document Your Symptom Timeline

Create a chronological summary of your EB journey:

Diagnosis confirmation:

  • Date of genetic testing and results
  • EB subtype (junctional vs. dystrophic)
  • Specific gene mutation (COL7A1, COL17A1, LAMB3, etc.)
  • Testing facility and report availability

Current wound status:

  • Location, size, and duration of target wounds
  • Pain levels during dressing changes (1-10 scale)
  • Frequency of new blister formation
  • Impact on daily activities and sleep

Catalog Treatments Tried and Failed

Aetna CVS Health expects evidence of standard wound care attempts before approving Filsuvez. Document:

Basic wound care tried:

  • Non-adherent dressings (petrolatum, foam, silicone)
  • Topical antibiotics (mupirocin, silver sulfadiazine)
  • Hydrogel sheets and biosynthetic dressings
  • Medicated honey or specialized wound care products

Outcomes and limitations:

  • Duration of each treatment
  • Reasons for discontinuation (ineffective, side effects, cost)
  • Objective measures (wound size changes, healing time)
  • Photos or measurements if available

Note Functional Impact

Quantify how current wound care affects your life:

  • Days of work/school missed
  • Activities you can't participate in
  • Sleep disruption from pain
  • Caregiver burden and time requirements

This information strengthens the medical necessity argument and demonstrates the urgency of improved treatment.

Build Your Evidence Kit

Essential Medical Records

Work with your healthcare team to gather:

Genetic confirmation:

  • Complete genetic test report showing EB subtype
  • Laboratory letterhead and contact information
  • Date of testing and methodology used

Wound documentation:

  • Recent clinic notes with wound measurements
  • Photographs showing wound characteristics
  • Dressing change logs or wound care records

Treatment history:

  • Medication lists with start/stop dates
  • Prior authorization denials for other treatments
  • Specialist consultation notes

Supporting Clinical Literature

Your doctor may reference these sources in the medical necessity letter:

Insurance Documentation

Collect your coverage details:

  • Current insurance card and member ID
  • Evidence of Coverage (EOC) document
  • Formulary information for your plan year
  • Previous denial letters if applicable

Medical Necessity Letter Structure

Your doctor will craft a letter of medical necessity following this evidence-based template:

Patient and Diagnosis Section

  • Complete demographics and insurance information
  • Specific EB subtype with genetic confirmation
  • ICD-10 codes (Q81.0 for junctional EB, Q81.2 for dystrophic EB)
  • Treating specialist credentials and experience

Clinical Rationale

  • Current wound characteristics meeting FDA criteria
  • Documentation of standard care attempts and outcomes
  • Explanation of why alternatives are insufficient
  • Reference to Phase 3 trial efficacy data

Treatment Plan

  • Proposed dosing (typically one 25mL tube daily)
  • Duration of initial authorization request (3-6 months)
  • Monitoring plan and outcome measures
  • Integration with existing wound care protocols

Supporting Evidence

  • Attached genetic testing results
  • Wound photographs and measurements
  • Previous treatment documentation
  • Relevant clinical literature citations
From our advocates: "We've found that letters including specific wound measurements, clear photos, and a detailed timeline of failed treatments have the highest approval rates. The key is showing Aetna CVS Health exactly how the patient meets every FDA criterion."

Support Your Doctor's Peer-to-Peer Review

If the initial request is denied, Aetna offers peer-to-peer review where your doctor speaks directly with an Aetna medical director.

Prepare Your Provider

  • Offer flexible scheduling windows for the call
  • Summarize key points in a one-page brief
  • Provide contact information for urgent scheduling
  • Share any additional documentation that emerged since submission

Key Discussion Points

Your doctor should emphasize:

  • FDA approval status: Filsuvez is the only FDA-approved topical for EB wounds
  • Genetic confirmation: Clear documentation of eligible EB subtype
  • Treatment failures: Specific standard therapies tried without success
  • Quality of life impact: Functional limitations and caregiver burden
  • Safety profile: Favorable adverse event profile in clinical trials

Timeline Expectations

Peer-to-peer reviews typically occur within 24-72 hours of request, with decisions communicated immediately after the call.

After Your Visit: Stay Organized

Document Everything

  • Save copies of all submitted forms and attachments
  • Record confirmation numbers from online submissions
  • Note the names of staff members you speak with
  • Keep a timeline of all communications

Use Patient Portals Effectively

  • Check for status updates on prior authorization requests
  • Message your provider team with questions or new information
  • Upload additional documentation if requested
  • Set notifications for important updates

Prepare for Follow-up

  • Schedule a follow-up appointment 2-3 weeks out
  • Plan what to do if approved (pharmacy coordination, insurance verification)
  • Prepare for potential denial (gather appeal documents, review timeline)

Respectful Persistence and Appeals

Appropriate Follow-up Cadence

  • Week 1: Confirm submission and check for processing
  • Week 2: Inquire about timeline if no response received
  • Week 3: Request status update and escalation if needed
  • Beyond 30 days: Consider formal complaint to Michigan DIFS

Escalation Strategies

If facing delays or denials:

  1. Request supervisor review of the initial decision
  2. Submit additional documentation addressing specific denial reasons
  3. Request expedited review if medically urgent
  4. File formal appeal following Michigan timelines

Professional Communication

  • Always be courteous with insurance representatives
  • Keep detailed notes of all phone conversations
  • Follow up phone calls with written confirmation
  • Involve your provider team in escalation decisions

Coverage Requirements at a Glance

Requirement Details Documentation Needed Source
Prior Authorization Required for all plans Complete PA form via Availity or fax Aetna PA Requirements
Age Limit 6 months or older Birth certificate or medical records FDA Label
EB Subtype Junctional or dystrophic only Genetic testing report FDA Approval
Wound Criteria Partial-thickness, 10-50 cm², ≥3 weeks Clinical measurements, photos Clinical Guidelines
Infection Status No active infection Recent wound culture or clinical assessment FDA Label
Specialist Involvement EB specialist or experienced dermatologist Provider credentials, consultation notes Aetna Policy

Michigan Appeals Process

If Aetna CVS Health denies your Filsuvez request, Michigan provides strong consumer protections through the Department of Insurance and Financial Services (DIFS).

Internal Appeal Timeline

  • Submit within: 180 days of denial notice
  • Decision required: 30 days standard, 72 hours expedited
  • How to file: Through Aetna member portal or written request
  • Required documents: Original denial letter, medical records, provider support

External Review Process

After exhausting internal appeals, you have 127 days to request external review through Michigan DIFS:

Contact Information:

Timeline:

  • Standard review: 60 days maximum
  • Expedited review: 72 hours with physician letter stating urgency
  • Decision binding: Yes, insurers must comply with IRO decisions

Required Documentation

  • Copy of final internal denial letter
  • Complete medical records supporting the request
  • Physician statement of medical necessity
  • Any additional clinical literature or guidelines

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements by identifying specific denial reasons and crafting point-by-point rebuttals aligned to each payer's own rules and policies.

FAQ

How long does Aetna CVS Health prior authorization take for Filsuvez in Michigan? Standard decisions are required within 72 hours of receiving complete documentation. Over 95% of eligible requests are approved within 24 hours when properly documented.

What if Filsuvez is not on my formulary? You can request a formulary exception through the same prior authorization process. Your doctor must demonstrate medical necessity and explain why formulary alternatives are inappropriate for your EB subtype.

Can I request an expedited appeal if my wounds are worsening? Yes. If waiting for standard review would seriously jeopardize your health, request expedited review with a physician letter documenting the urgency. Decisions are required within 24 hours.

Does step therapy apply to Filsuvez? Aetna may require documentation of standard wound care attempts before approving Filsuvez. This isn't traditional step therapy but rather evidence that FDA-approved indications are met.

What happens if I move from Michigan to another state? Appeal rights and timelines vary by state. Contact your new state's insurance department for specific external review processes, though federal protections still apply.

How much does Filsuvez cost without insurance? GoodRx shows prices starting around $27,631 for common quantities, though actual costs vary. Manufacturer support programs may be available through Chiesi Total Care.

Can my family member help with the appeal process? Yes, with proper authorization. Michigan law allows designated representatives to file appeals on your behalf. Complete appropriate consent forms with your insurer.

What if I have both Medicare and Medicaid coverage? Coordination of benefits can be complex. Work with your provider team and Counterforce Health to ensure proper submission to the primary payer first, then secondary coverage as needed.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual policy terms and medical circumstances. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For additional support with insurance appeals and prior authorization processes, consider consulting with Counterforce Health, which specializes in helping patients navigate complex coverage requirements for specialty medications.

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