PrEP Apretude LA denied as non-formulary 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 Non-Formulary — and How to Appeal

A non-formulary denial means Apretude (cabotegravir extended-release injectable suspension) is not included on your specific Aetna plan's drug formulary, or is placed at a tier that makes it effectively inaccessible. Formulary placement decisions are made at the plan level and can vary significantly across different Aetna products. This type of denial is appealable through both a formulary exception process and, if that fails, a standard internal and external appeal.

## Why This Denial Is Appealable

Aetna and most commercial plans are required to have a formulary exception process under which a non-formulary drug can be covered when a formulary alternative is medically contraindicated, has been tried and failed, or when no formulary alternative is clinically appropriate for you. Because oral PrEP agents and injectable Apretude serve the same indication but are not clinically identical, a well-documented exception request has a strong basis — particularly when your prescriber can document why a formulary oral agent is not appropriate for you.

## Your Federal Appeal Rights

• ACA §2719 / ERISA §503 — Non-grandfathered commercial plans must provide internal appeal and independent external review for adverse benefit determinations, including formulary-exception denials.
• External review window — Typically approximately four months from the date of the adverse determination. Do not let this window close.
• Expedited review — Available when standard timing poses a clinical risk.

## Concrete Appeal Steps

1. Request a formulary exception — This is a separate process from the standard appeal and is the fastest pathway. Submit with your prescriber's letter explaining why the formulary alternative(s) are not appropriate for you. 2. File a Level 1 internal appeal simultaneously or on denial — If the formulary exception is denied, escalate immediately to a formal internal appeal. 3. Obtain and review the current Aetna formulary for your plan — identify whether any long-acting injectable PrEP agent is listed, and at what tier. 4. Escalate to external review if internal appeals are exhausted.

## Documentation to Gather

• Prescriber medical-necessity letter for formulary exception — must explain why the formulary oral PrEP alternative(s) are not clinically appropriate for you (e.g., documented adherence barriers, clinical history, patient-specific factors).
• Trial and failure documentation for any oral PrEP agent previously used — pharmacy dispensing records showing gaps, or chart notes documenting adherence challenges.
• HIV testing and clinical history confirming ongoing HIV-negative status and active PrEP indication.
• Current Aetna formulary document for your plan year — identify the applicable formulary exception criteria.
• Aetna formulary exception policy — obtain the specific criteria required for non-formulary approval.

## Criteria-Mapping Structure

List every formulary exception criterion from the Aetna policy. For each criterion, write one sentence citing the specific chart note, date, and clinician whose documentation satisfies it. Present this as a numbered exhibit in both the formulary exception request and the formal appeal letter so every requirement is visibly addressed.