By Counterforce Health Team in Tavneos (avacopan) —

Work With Your Doctor to Get Tavneos (avacopan) Approved by Aetna CVS Health in New Jersey: Complete Provider Collaboration Guide

Answer Box: Getting Started Today

To get Tavneos (avacopan) approved by Aetna CVS Health in New Jersey: Your doctor must submit a prior authorization request with complete documentation showing severe active ANCA-associated vasculitis (GPA/MPA), use as adjunctive therapy with standard treatments, and specialist involvement. If denied, you have 180 days to appeal internally, then file for external review through New Jersey's IHCAP program within 4 months. First step today: Schedule a visit to review your treatment history and gather clinical documentation for the medical necessity letter.

Table of Contents

  1. Set Your Goal: What Approval Requires
  2. Visit Preparation: Building Your Case
  3. Evidence Kit: Essential Documentation
  4. Medical Necessity Letter Structure
  5. Peer-to-Peer Review Support
  6. After Your Visit: Next Steps
  7. Respectful Persistence: Follow-Up Strategy
  8. Appeals Playbook for New Jersey
  9. FAQ: Common Questions
  10. Sources & Further Reading

Set Your Goal: What Approval Requires

Tavneos (avacopan) requires prior authorization from Aetna CVS Health for ANCA-associated vasculitis. Your partnership with your doctor is crucial because approval hinges on demonstrating:

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed
Specialist Prescriber Rheumatologist, nephrologist, or pulmonologist Provider credentials verification
Confirmed Diagnosis Severe active GPA or MPA with ANCA positivity Lab results, biopsy reports, imaging
Adjunctive Use Combined with rituximab/cyclophosphamide + steroids Treatment plan documentation
Prior Authorization Aetna precertification required Completed PA forms with clinical rationale
Medical Necessity Clear clinical justification for Tavneos over alternatives Letter addressing denial criteria
Note: Tavneos costs approximately $17,000 per month, making thorough documentation essential for approval.

Your role is to provide complete medical history and advocate for your needs. Your doctor's role is to present the clinical case that meets Aetna's specific criteria.

Visit Preparation: Building Your Case

Come to your appointment prepared with a comprehensive timeline that demonstrates medical necessity.

Symptom Timeline Documentation

Create a detailed record including:

  • Initial symptoms and when they started
  • Diagnosis timeline including all tests performed
  • Functional impact on daily activities, work, or quality of life
  • Emergency visits or hospitalizations related to vasculitis

Treatment History Summary

Document every therapy you've tried:

Standard Therapies:

  • Glucocorticoids (prednisone doses, duration, side effects)
  • Rituximab (infusion dates, response, complications)
  • Cyclophosphamide (oral/IV, duration, toxicities)
  • Other immunosuppressants (methotrexate, azathioprine)

Treatment Failures/Intolerance:

  • Inadequate disease control despite appropriate dosing
  • Serious side effects requiring discontinuation
  • Contraindications to standard therapies
  • Steroid-related complications (diabetes, osteoporosis, infections)

Current Disease Activity

Prepare to discuss:

  • Recent flares or organ involvement
  • Laboratory trends (ANCA titers, creatinine, urinalysis)
  • Imaging findings showing active disease
  • Birmingham Vasculitis Activity Score if available

Evidence Kit: Essential Documentation

Work with your doctor to compile a comprehensive evidence package.

Laboratory and Imaging Records

Required Lab Results:

  • ANCA serology (PR3-ANCA for GPA, MPO-ANCA for MPA)
  • Complete blood count and inflammatory markers (ESR, CRP)
  • Comprehensive metabolic panel including kidney function
  • Urinalysis showing active sediment if renal involvement
  • Liver function tests (baseline for Tavneos monitoring)

Imaging Studies:

  • Chest CT showing pulmonary involvement
  • Sinus imaging for upper respiratory tract disease (GPA)
  • Renal ultrasound if kidney involvement

Clinical Guidelines Support

Your doctor should reference current treatment guidelines:

Medication History Summary

Create a table format showing:

Medication Dates Used Dose/Duration Outcome Reason for Discontinuation
Prednisone MM/YY-MM/YY Dose range Partial response Steroid toxicity
Rituximab MM/YY-MM/YY Standard protocol Good initial response Disease breakthrough
Cyclophosphamide MM/YY-MM/YY Dose/route Response details Toxicity concerns

Medical Necessity Letter Structure

Your doctor will need to craft a compelling medical necessity letter addressing Aetna's specific criteria.

Essential Letter Components

Patient Identification Section:

  • Full name, date of birth, member ID
  • Policy holder information
  • Requesting provider credentials and specialty

Clinical Diagnosis:

  • Specific ANCA-associated vasculitis type (GPA or MPA)
  • ICD-10 codes (M31.30 for GPA, M31.7 for MPA)
  • ANCA subtype and titer results
  • Organ systems involved

Treatment History and Rationale:

  • Detailed prior therapy trials with outcomes
  • Evidence of standard therapy limitations
  • Clinical rationale for Tavneos as adjunctive treatment
  • Expected benefits and monitoring plan

Supporting Evidence:

  • Reference to FDA-approved indication for severe active AAV
  • Published clinical trial data supporting efficacy
  • Professional society guideline recommendations
  • Specialist consultation notes
Tip: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned to each payer's specific rules.

Peer-to-Peer Review Support

If the initial prior authorization is denied, your doctor may request a peer-to-peer review with Aetna's medical director.

Preparation for P2P Discussion

Offer Availability Windows:

  • Provide your doctor with flexible scheduling options
  • Be available for additional questions during the review
  • Prepare a concise case summary highlighting key points

Clinical Summary for Provider: Create a one-page summary including:

  • Patient demographics and diagnosis
  • Treatment timeline with specific dates and outcomes
  • Current disease status and functional limitations
  • Clear rationale for Tavneos necessity

P2P Discussion Points

Your doctor should be prepared to discuss:

  • Why standard therapy alone is insufficient
  • Specific contraindications to steroid continuation
  • Risk-benefit analysis favoring Tavneos
  • Monitoring plan for hepatotoxicity and infections

Phone Script for Provider: "I'm calling to discuss my patient with severe active GPA who requires Tavneos as adjunctive therapy. Despite standard treatment with rituximab and steroids, they continue to have active disease with significant steroid toxicity. The clinical evidence supports Tavneos for steroid-sparing in this exact scenario, and I have comprehensive documentation of treatment failures and current disease activity."

After Your Visit: Next Steps

Documentation to Save

Keep copies of:

  • Prior authorization submission confirmation
  • Medical necessity letter sent to Aetna
  • All supporting clinical documentation
  • Provider portal communications
  • Denial letters with specific reasons cited

Portal Communication Strategy

Effective messaging through patient portals:

  • Use subject lines like "Tavneos PA - Additional Information Needed"
  • Reference specific Aetna policy numbers when available
  • Attach relevant lab results or imaging reports
  • Request read receipts when possible

Timeline Tracking

Monitor these key dates:

  • PA submission date
  • Aetna's decision deadline (typically 30-45 days)
  • Appeal deadline if denied (180 days from denial)
  • External review deadline (4 months from final denial)

Respectful Persistence: Follow-Up Strategy

Appropriate Contact Cadence

Week 1-2: Allow processing time, no contact needed Week 3: Status check via provider portal or phone Week 4: Follow-up if no response, offer additional documentation Week 5+: Escalate to peer-to-peer review request

Escalation Scripts

For Provider Staff: "I'm following up on the Tavneos prior authorization submitted on [date]. The patient has severe active vasculitis and we haven't received a decision within the expected timeframe. Can you provide a status update and expedite the review?"

For Patient Advocacy: "I'd like to request a peer-to-peer review for my Tavneos prior authorization. My doctor has additional clinical information that wasn't fully considered in the initial review."

When to Involve Counterforce Health

Consider professional appeal assistance when:

  • Multiple denials despite complete documentation
  • Complex clinical scenarios requiring specialized expertise
  • Time constraints for urgent medical needs
  • Need for systematic appeal strategy across multiple payers

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by identifying denial basis and drafting targeted rebuttals aligned to each plan's specific rules.

Appeals Playbook for New Jersey

If Aetna denies your Tavneos prior authorization, New Jersey provides robust appeal rights.

Internal Appeals Process

Level 1 Appeal:

  • Timeline: File within 180 days of denial notice
  • Decision time: 30-45 days for standard review, 72 hours for expedited
  • Submission: Via Aetna member portal or written request

Level 2 Appeal:

  • Timeline: File within 60 days of Level 1 denial
  • Decision time: 30 days for standard review
  • Requirements: Include all new supporting documentation

External Review Through IHCAP

After exhausting internal appeals, New Jersey offers independent external review through the Independent Health Care Appeals Program.

Eligibility Requirements:

  • Completed Aetna's internal appeal process
  • Fully-insured New Jersey plan (check member ID card)
  • Denial based on medical necessity or experimental/investigational determination

Submission Process:

  • Timeline: Within 4 months of final internal denial
  • Administrator: Maximus Federal Services
  • Forms: Complete external appeal application with general release form
  • Cost: No fee to patient; insurer pays review costs

Required Documentation:

  • Final denial notice from Aetna
  • All medical records supporting Tavneos necessity
  • Treatment history and failure documentation
  • Specialist letters supporting medical necessity

Contact Information:

  • Online portal: njihcap.maximus.com
  • Mailing address: Maximus Federal-NJ IHCAP, 3750 Monroe Ave, Suite 705, Pittsford, NY 14534
  • Fax: 585-425-5296
  • Email: [email protected]

Expedited Appeals

For urgent situations where delay could cause serious harm:

  • Timeline: 48-hour decision for external review
  • Requirements: Physician certification of urgency
  • Submission: Mark clearly as "EXPEDITED" on all forms

FAQ: Common Questions

How long does Aetna CVS Health prior authorization take in New Jersey? Standard prior authorization decisions are typically made within 30-45 days. Expedited reviews for urgent cases are completed within 72 hours with physician certification of medical urgency.

What if Tavneos is non-formulary on my Aetna plan? You can request a formulary exception with documentation of medical necessity and failure of formulary alternatives. The process is similar to prior authorization but requires additional justification for non-preferred medication use.

Can I request an expedited appeal if my vasculitis is worsening? Yes, if your physician certifies that delay in treatment could cause serious jeopardy to your health or maximum function, both Aetna's internal appeals and New Jersey's external review offer expedited timelines.

Does step therapy apply if I've failed treatments outside New Jersey? Treatment failures from other states typically count toward step therapy requirements, but you must provide complete documentation from all previous providers to demonstrate adequate trials and failures.

What happens if the external review overturns Aetna's denial? Aetna must comply with the Independent Utilization Review Organization's decision and cover Tavneos. They must submit a written implementation report within 10 business days confirming coverage approval.

How much will Tavneos cost if approved? With Aetna coverage, your out-of-pocket cost depends on your specific plan's specialty tier copayment or coinsurance. Amgen offers patient assistance programs that may help reduce costs for eligible patients.

Can my doctor file the external appeal on my behalf? Yes, New Jersey allows providers to file external appeals with patient consent. This can be helpful for complex clinical cases requiring detailed medical documentation.

What if my employer plan is self-funded rather than fully-insured? Self-funded ERISA plans follow federal appeal rules rather than New Jersey's IHCAP process. Check your plan documents or contact HR to determine if your plan is fully-insured or self-funded.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage processes and should not replace professional medical advice. Treatment decisions should always be made in consultation with qualified healthcare providers. For specific questions about your coverage, contact Aetna CVS Health member services or consult with your healthcare team. New Jersey residents can contact the Department of Banking and Insurance Consumer Hotline at 1-800-446-7467 for additional assistance with insurance appeals.

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