By Counterforce Health Team in Eylea / Lucentis (aflibercept / ranibizumab) —

Complete Guide to Getting Eylea and Lucentis Covered by Aetna CVS Health in Georgia: Prior Authorization, Appeals, and Step-by-Step Requirements

Answer Box: How to Get Eylea/Lucentis Covered by Aetna CVS Health in Georgia

Aetna CVS Health requires prior authorization for both Eylea (aflibercept) and Lucentis (ranibizumab) in Georgia, typically mandating step therapy with bevacizumab first. The fastest path to approval: 1) Have your eye doctor document why bevacizumab failed or is contraindicated, 2) Submit a comprehensive medical necessity letter with OCT imaging and visual acuity records through Aetna's provider portal, 3) If denied, file an internal appeal within 180 days, then pursue Georgia's external review within 60 days of final denial through the Georgia Department of Insurance.

Table of Contents

Who Should Use This Guide

This guide is for Georgia residents with Aetna CVS Health coverage who need Eylea or Lucentis for:

  • Wet age-related macular degeneration (AMD)
  • Diabetic macular edema
  • Diabetic retinopathy
  • Retinal vein occlusion with macular edema

Expected outcome: With proper documentation, most medically appropriate requests get approved. If initially denied, Georgia's external review process gives you a second chance with independent medical experts who overturn many wrongful denials.

Member & Plan Basics

Verify Active Coverage

Before starting, confirm your Aetna CVS Health plan is active and includes prescription drug coverage. Check your member ID card or log into the Aetna member portal.

Plan Type Considerations

  • Commercial plans: Follow standard prior authorization process
  • Medicare Advantage: May have different formulary requirements
  • Self-insured employer plans: State appeal rights may not apply

Authorization Requirements

Aetna requires prior authorization for both Eylea and Lucentis before administration. Most requests are processed within 24-48 hours, though complex cases may take up to 45 business days.

Clinical Criteria

FDA-Approved Indications

Both medications must be used for FDA-approved indications:

  • Eylea: Wet AMD, diabetic macular edema, diabetic retinopathy, retinal vein occlusion
  • Lucentis: Similar indications with specific dosing protocols

Step Therapy Requirements

Aetna typically requires bevacizumab (Avastin) first unless contraindicated. Your doctor must document:

  • Previous bevacizumab trial with specific dates
  • Lack of efficacy or adverse reactions
  • Medical reasons why bevacizumab isn't appropriate
Note: Some plans may allow direct access to Eylea/Lucentis for specific clinical scenarios. Check your formulary.

Dosing and Duration

Document the proposed treatment schedule:

  • Loading phase frequency (typically monthly)
  • Maintenance schedule (every 8-16 weeks)
  • Total expected duration of therapy

Coding Requirements

ICD-10 Diagnosis Codes

Use specific codes for your condition:

Condition ICD-10 Code Description
Wet AMD H35.32 Exudative age-related macular degeneration
Diabetic macular edema E11.311 Type 2 diabetes with unspecified diabetic retinopathy with macular edema
Central retinal vein occlusion H34.81 Central retinal vein occlusion

HCPCS J-Codes

  • Eylea: J0178
  • Lucentis: J2778

Documentation Requirements

Ensure your provider includes:

  • Correct ICD-10 codes for your specific diagnosis
  • Appropriate J-codes for the medication
  • Units and dosage information

Documentation Packet

Provider Note Elements

Your ophthalmologist's notes must include:

  • Complete eye exam findings
  • Visual acuity measurements (both eyes)
  • Detailed retinal assessment
  • OCT imaging interpretation
  • Treatment history and response

Medical Necessity Letter Components

Counterforce Health helps patients and clinicians create targeted medical necessity letters that address payer-specific requirements, pulling the right clinical evidence and weaving it into appeals that meet Aetna's criteria. A comprehensive letter should include:

  1. Patient demographics and diagnosis
  2. Clinical presentation and severity
  3. Prior treatment failures with specific details:
    • Medication names and dates
    • Duration of each trial
    • Reasons for discontinuation
  4. Why Eylea/Lucentis is medically necessary
  5. Supporting clinical evidence and guidelines
  6. Proposed treatment plan and monitoring

Required Attachments

  • Recent OCT imaging showing disease activity
  • Visual acuity records (current and historical)
  • Prior treatment documentation
  • Relevant lab results if applicable
  • Clinical photos if available

Submission Process

Correct Form Version

Use Aetna's current prior authorization form - forms are updated regularly, so verify you have the latest version.

Submission Methods

Primary: Aetna provider portal Alternative: Fax to the number listed on your specific plan's PA form

Common Rejection Fields

Ensure these fields are complete:

  • Patient ID number (exactly as on insurance card)
  • Prescriber NPI number
  • Specific drug name and strength
  • ICD-10 codes
  • Prior authorization number (if resubmission)

Specialty Pharmacy Routing

CVS Specialty Preference

Aetna often requires specialty medications like Eylea and Lucentis to be dispensed through CVS Specialty. Your doctor may need to:

  • Transfer the prescription to CVS Specialty
  • Coordinate delivery timing with injection appointments
  • Verify patient enrollment in specialty pharmacy services

Transfer Steps

  1. Doctor sends prescription to CVS Specialty
  2. CVS Specialty contacts patient for enrollment
  3. Medication ships to doctor's office or infusion center
  4. Coordinate delivery with appointment schedule

After Submission

Confirmation Numbers

Always obtain and record:

  • Prior authorization reference number
  • Date of submission
  • Name of person who accepted the submission

Status Check Schedule

  • Day 2: Verify receipt of submission
  • Day 5: Check for requests for additional information
  • Day 10: Follow up if no decision received
  • Day 15: Escalate if approaching deadline

What to Record

Keep detailed notes including:

  • All communication dates and times
  • Names of representatives spoken with
  • Reference numbers for all interactions
  • Copies of all submitted documents

Common Denial Reasons & How to Fix Them

Denial Reason How to Fix Required Documentation
Step therapy not completed Document bevacizumab failure/contraindication Prior treatment records, adverse reaction notes
Insufficient medical necessity Strengthen clinical justification Additional OCT images, visual field tests, clinical guidelines
Missing documentation Submit complete packet All required attachments per checklist
Non-formulary status Request formulary exception Comparative effectiveness data, cost analysis
Quantity/frequency limits Justify dosing schedule Clinical protocols, treatment response data

Georgia Appeals Process

Internal Appeals

Timeline: File within 180 days of denial Decision timeframe: 45 business days (standard) or 72 hours (expedited) How to file: Through Aetna provider portal or by mail

Georgia External Review

If your internal appeal is denied, Georgia law provides additional protection:

Timeline: Must file within 60 days of final internal denial Process: Submit application to Georgia Department of Insurance Cost: Free to consumers Decision timeline: 30 business days (standard) or 72 hours (expedited)

From our advocates: We've seen many Georgia patients successfully overturn Aetna denials for Eylea and Lucentis through the state's external review process. The key is submitting comprehensive clinical documentation that clearly demonstrates medical necessity and prior treatment failures. Independent reviewers often have a different perspective than the initial utilization management team.

When to Request Expedited Review

Request expedited appeals when:

  • Delay could seriously jeopardize vision
  • Current treatment is failing rapidly
  • Risk of permanent vision loss

Georgia Consumer Resources

  • Georgia DOI Consumer Services: 1-800-656-2298
  • Online complaint form: Available on DOI website
  • Georgians for a Healthy Future: Provides consumer assistance with appeals

Quick Reference Checklist

Before You Start:

  • Verify active Aetna coverage
  • Confirm drug is on formulary
  • Check if step therapy applies
  • Gather all medical records

Clinical Documentation:

  • Complete eye exam notes
  • OCT imaging (current and historical)
  • Visual acuity measurements
  • Prior treatment history
  • Contraindications to alternatives

Submission Requirements:

  • Current PA form completed
  • Medical necessity letter
  • All supporting attachments
  • Correct ICD-10 and J-codes
  • Provider NPI and patient ID verified

After Denial:

  • File internal appeal within 180 days
  • Prepare for Georgia external review (60-day deadline)
  • Keep detailed records of all communications

FAQ

How long does Aetna prior authorization take in Georgia? Most requests are processed within 24-48 hours. Complex cases may take up to 45 business days. Expedited requests are handled within 72 hours.

What if Eylea or Lucentis is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and why formulary alternatives aren't appropriate for your condition.

Can I request an expedited appeal if my vision is deteriorating? Yes. If delays could seriously jeopardize your vision or health, you can request expedited processing at both internal and external review levels.

Does step therapy apply if I failed bevacizumab in another state? Yes, prior treatment failures from other states should count. Ensure your doctor documents the previous trial with specific dates and outcomes.

What happens if I miss the 60-day deadline for Georgia external review? The deadline is strict, but you may have other options. Contact Georgia DOI Consumer Services at 1-800-656-2298 to discuss your situation.

How much do Eylea and Lucentis cost without insurance? List prices range from approximately $1,200 to $2,500 per injection. Both manufacturers offer patient assistance programs that may help reduce costs.

Can my family member help with the appeal process? Yes, but you'll need to designate them as your authorized representative in writing. Aetna has specific forms for this purpose.

What's the success rate for appeals in Georgia? While specific statistics vary, many wrongful denials are overturned through Georgia's external review process, especially when comprehensive clinical documentation supports medical necessity.

Counterforce Health specializes in turning insurance denials into successful appeals by creating evidence-backed medical necessity letters tailored to each payer's specific requirements. Visit counterforcehealth.org to learn how we help patients, clinicians, and specialty pharmacies navigate complex prior authorization and appeal processes.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeal processes. It is not medical advice. Always consult with your healthcare provider about your specific medical condition and treatment options. Insurance coverage and appeal procedures may vary by plan and can change over time. Verify current requirements with your insurer and consult official sources for the most up-to-date information.

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