PrEP Apretude LA denied as duplicate or overlapping therapy by Aetna?

Aetna's specific coverage criteria for prep apretude la are defined in its own published medical/coverage policy and the FDA-approved prescribing label. A successful appeal documents that your medical records satisfy each criterion those sources list — confirmed diagnosis, any required prior treatments (with dates and outcomes), and clinical severity. If the exact criteria weren't included with your denial, request them in writing; your appeal then maps each requirement to the matching fact in your chart.

## Why Aetna Denied Apretude (Long-Acting Cabotegravir) as "Duplicate Therapy" — and How to Appeal

Apretude (cabotegravir extended-release injectable suspension) is a long-acting injectable form of HIV pre-exposure prophylaxis (PrEP). A duplicate-therapy denial typically means Aetna's system detected that you have an active prescription for an oral PrEP agent — usually a daily oral tablet — and flagged the injectable as redundant. This is a clinical misapplication: injectable and oral PrEP are not interchangeable duplicates. They differ in mechanism of administration, pharmacokinetics, and — critically for many patients — adherence profile. The reason your prescriber selected Apretude over oral PrEP is a clinical decision, and the appeal should articulate that distinction.

## Why This Denial Is Appealable

Duplicate-therapy edits are generated by automated claims-processing rules, not clinical review. Federal law requires that adverse benefit determinations be subject to individual clinical review. The fact that two agents share the same indication does not make them interchangeable for a given patient, and Aetna's clinical reviewers are required to evaluate your specific circumstances.

## Your Federal Appeal Rights

• ACA §2719 / ERISA §503 — Non-grandfathered commercial and employer-sponsored plans must provide full-and-fair internal appeal and independent external review.
• External review window — Typically approximately four months from the date of the adverse determination. Do not let this deadline pass.
• Expedited review — If your clinical situation makes a delay in initiating or continuing PrEP a serious risk (e.g., a recent potential exposure), expedited processing is available and typically resolves within 72 hours.

## Concrete Appeal Steps

1. Request the denial in writing — Obtain the Explanation of Benefits (EOB) and the specific duplicate-therapy rule Aetna applied. 2. Confirm the oral PrEP prescription status — If the oral agent was already discontinued or is being discontinued, document this with pharmacy records and a prescriber note. 3. File a Level 1 internal appeal — Your prescriber's letter should explain why injectable Apretude is clinically distinct from oral PrEP for you specifically (e.g., adherence challenges, patient preference that is clinically documented, pharmacokinetic considerations). 4. Escalate to Level 2 and external review if the internal appeal is denied.

## Documentation to Gather

• Prescriber letter explicitly addressing why injectable long-acting PrEP is medically necessary and not duplicative for this patient.
• Adherence history for any prior oral PrEP regimen, if applicable — pharmacy dispensing records showing gaps, or documentation of adherence barriers.
• HIV testing and clinical history confirming ongoing HIV-negative status and continued PrEP indication.
• Aetna's duplicate-therapy / formulary policy for PrEP — obtain the current version and map each requirement to your supporting documentation.

## Criteria-Mapping Structure

For each criterion in Aetna's applicable coverage policy, write one sentence identifying the specific chart note or document that satisfies it. Present this as a numbered list in your appeal cover letter so every criterion is visibly addressed, making it easy for the clinical reviewer to approve the appeal.