By Counterforce Health Team in Rebif (interferon beta-1a) —

Coding That Helps Get Rebif (Interferon Beta-1a) Approved by Aetna CVS Health in North Carolina: ICD-10, HCPCS, and NDC Guide

Answer Box: Getting Rebif Approved in North Carolina

Rebif (interferon beta-1a) requires prior authorization from Aetna CVS Health in North Carolina. The fastest approval path: (1) Use correct ICD-10 code G35.A for relapsing-remitting MS with documented disease activity, (2) Submit complete prior authorization through CVS Specialty with step therapy documentation, and (3) Include comprehensive treatment history showing failure/intolerance of preferred DMTs. Start today by verifying your plan requires CVS Specialty dispensing and gathering MRI reports plus prior therapy records. Appeals through Smart NC external review succeed in approximately 43% of specialty drug cases.

Table of Contents

Coding Basics: Medical vs. Pharmacy Benefit Paths

Rebif (interferon beta-1a) follows specialty pharmacy benefit pathways under most Aetna CVS Health plans in North Carolina. Understanding which benefit applies determines your coding approach and submission requirements.

Pharmacy Benefit Path (Most Common)

  • Route: CVS Specialty Pharmacy exclusively
  • Coding: NDC-based claims with quantity/days supply
  • Prior Auth: Required through CVS Caremark PA system
  • Timeline: 5-7 business days standard, 72 hours expedited

Medical Benefit Path (Limited)

  • Route: Provider office buy-and-bill (rare for Rebif)
  • Coding: HCPCS J-codes with unit calculations
  • Prior Auth: Through Aetna medical review
  • Restrictions: Most plans route to pharmacy benefit only
Note: Aetna's 2024 specialty drug policies typically require CVS Specialty dispensing for Rebif, making pharmacy benefit coding the primary pathway.

ICD-10 Mapping for Multiple Sclerosis

New FY 2026 ICD-10 codes (effective October 1, 2025) require specific MS phenotype documentation. The generic G35 code is no longer billable.

Primary Codes for Rebif Coverage

ICD-10 Code Description Documentation Required
G35.A Relapsing-remitting multiple sclerosis Clear RRMS phenotype, relapse history
G35.C1 Active secondary progressive MS SPMS with documented activity (relapses/MRI)
G35.C0 Secondary progressive MS, unspecified SPMS without activity specification
G35.D Multiple sclerosis, unspecified Use only when phenotype unknown

Documentation Words That Support Coding

For G35.A (RRMS):

  • "Relapsing-remitting multiple sclerosis"
  • "Recurrent clinical attacks with recovery"
  • "Stable between relapses"

For G35.C1 (Active SPMS):

  • "Active secondary progressive multiple sclerosis"
  • "Gradual worsening with ongoing relapses"
  • "MRI activity with progressive course"

Clinically Isolated Syndrome (CIS)

CIS doesn't have a specific 2026 code but is covered under Rebif's FDA indication for "relapsing forms of MS." Document clearly:

  • "Clinically isolated syndrome"
  • "Single demyelinating attack"
  • "High risk for MS conversion"

Product Coding: HCPCS, J-Codes, and NDC

NDC Codes (Pharmacy Benefit)

Rebif prefilled syringes and autoinjectors use specific NDC codes:

22 mcg/0.5 mL:

  • Prefilled syringe: NDC 44087-2222-01
  • Autoinjector: NDC 44087-2244-01

44 mcg/0.5 mL:

  • Prefilled syringe: NDC 44087-4444-01
  • Autoinjector: NDC 44087-4466-01

HCPCS/J-Codes (Medical Benefit)

When medical benefit applies:

  • Q3028: Injection, interferon beta-1a, 1 mcg for subcutaneous use
  • J1826: Injection, interferon beta-1a, 30 mcg (alternative coding)

Units Math for Billing

Pharmacy claims: Bill quantity as number of individual syringes/autoinjectors

  • 12 syringes = 28-day supply (3x weekly dosing)
  • 36 syringes = 84-day supply (where allowed)

Medical claims using Q3028:

  • 22 mcg dose = 22 units
  • 44 mcg dose = 44 units
  • Bill actual micrograms administered, not "per injection"

Clean Prior Authorization Anatomy

A complete Rebif PA submission includes these elements with proper coding support:

Required Clinical Information

  1. Diagnosis coding: G35.A, G35.C1, or appropriate MS code
  2. Disease activity documentation:
    • MRI reports showing lesions
    • Relapse dates and severity
    • EDSS scores if available
  3. Prior therapy history:
    • Names, dates, doses of previous DMTs
    • Reasons for discontinuation
    • Clinical outcomes

Step Therapy Documentation

Aetna CVS Health typically requires trial/failure of preferred agents:

  • First-line options: Other interferons, glatiramer acetate
  • Failure criteria: Ongoing relapses, MRI progression, intolerance
  • Contraindications: Document why preferred agents inappropriate

Safety Requirements

  • Recent CBC and liver function tests
  • Baseline depression screening
  • Cardiac evaluation if indicated

Frequent Pitfalls and Unit Conversions

Common Billing Errors

Wrong Pharmacy Network

Quantity Mismatches

  • Error: Billing "1 carton" instead of individual syringes
  • Fix: Bill 12 syringes for 28-day supply
  • Verification: Match quantity to FDA-approved dosing

Unit Conversion Problems

  • Error: Using J1826 (30 mcg units) for 44 mcg dose
  • Fix: Use Q3028 (1 mcg units) = 44 units for 44 mcg
  • Check: Cross-reference HCPCS definitions

Missing Prior Authorization Elements

  • Incomplete step therapy documentation
  • Missing MRI reports from last 12 months
  • Inadequate failure documentation for preferred DMTs

Verification with Aetna CVS Health Resources

Pre-Submission Checklist

  1. Confirm specialty pharmacy requirement
  2. Validate coding
    • ICD-10: Match to documented MS phenotype
    • NDC: Use correct strength and formulation
    • Quantity: Align with dosing schedule
  3. Check PA status

Quick Audit Checklist

Before Submission:

  • ICD-10 code matches documented MS phenotype (G35.A, G35.C1)
  • NDC corresponds to prescribed strength and device type
  • Quantity equals number of syringes for days supply
  • Prior authorization approved and current
  • CVS Specialty confirmed as dispensing pharmacy
  • Step therapy requirements documented
  • Safety labs current (CBC, LFTs within 6 months)
  • MRI reports support disease activity claims

Red Flags to Avoid:

  • Using expired G35 code without phenotype
  • Billing 90-day supplies without plan approval
  • Missing contraindication documentation for preferred DMTs
  • Incomplete relapse history in PA request

Appeals Process in North Carolina

Internal Appeals with Aetna CVS Health

Level 1 Appeal

  • Deadline: 180 days from denial
  • Timeline: 30 days for standard, 72 hours expedited
  • Submission: Availity portal or fax with supporting documentation

Level 2 Appeal

  • When: After Level 1 denial
  • Includes: Peer-to-peer review option
  • Documentation: Enhanced clinical evidence, guideline citations

North Carolina External Review

After exhausting internal appeals, North Carolina residents can access independent external review through Smart NC.

Key Details:

  • Success rate: Approximately 43% for specialty drugs
  • Timeline: 45 days standard, 72 hours expedited
  • Contact: Smart NC at 1-855-408-1212
  • Binding: IRO decision is final and enforceable

Eligibility Requirements:

  • State-regulated plan (not self-funded ERISA)
  • Medical necessity denial
  • Completed internal appeals
  • Filed within 120 days of final internal denial

Medicare Part D (Aetna Medicare)

Coverage Decision Process:

  • Timeline: 72 hours standard, 24 hours expedited
  • Appeals: 60-day windows for each level
  • IRE Review: Independent Review Entity after Aetna levels

For North Carolina State Health Plan retirees using Aetna Medicare, additional appeal authorization forms may be required.

FAQ

How long does Aetna CVS Health prior authorization take for Rebif in North Carolina? Standard PA decisions typically take 5-7 business days. Expedited reviews for urgent medical situations are completed within 72 hours.

What if Rebif is non-formulary on my Aetna plan? Request a formulary exception with documentation of failure/intolerance to preferred DMTs. Include clinical rationale for Rebif specifically and guidelines supporting its use.

Can I request an expedited appeal for Rebif denial? Yes, if delay would jeopardize your health or ability to regain maximum function. For MS, this includes risk of relapse or permanent neurologic damage.

Does step therapy apply if I was stable on Rebif with a previous insurer? Document stability and risk of destabilization if switched. Many plans waive step therapy for established, effective therapy to prevent medical disruption.

What coding should I use for clinically isolated syndrome? Use G35.A for RRMS if CIS meets criteria for relapsing MS treatment, with clear documentation of "clinically isolated syndrome" in the medical record.

How do I verify CVS Specialty is required for my Aetna plan? Check your plan's formulary documents or call Aetna member services. Most specialty drugs under CVS-managed benefits require CVS Specialty dispensing.

At Counterforce Health, we help patients, clinicians, and specialty pharmacies transform insurance denials into successful appeals through evidence-based strategies. Our platform analyzes denial patterns and creates targeted rebuttals that align with payer policies and clinical guidelines, significantly improving approval rates for complex specialty medications like Rebif.

Throughout the prior authorization and appeals process, proper coding serves as the foundation for successful coverage decisions. By using the correct ICD-10 codes that reflect your documented MS phenotype and ensuring accurate NDC or HCPCS billing, you create a stronger case for medical necessity. Counterforce Health's systematic approach to appeals combines this coding accuracy with comprehensive clinical documentation, helping healthcare providers achieve better outcomes for their multiple sclerosis patients.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For assistance with North Carolina insurance appeals, contact Smart NC at 1-855-408-1212.

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