By Counterforce Health Team in Koselugo (selumetinib) —

Denied Koselugo (Selumetinib) Coverage by Aetna CVS Health in New Jersey? Complete Appeal Guide with Forms and Templates

Answer Box: Getting Koselugo (Selumetinib) Covered by Aetna CVS Health in New Jersey

Quick Path to Approval: Submit a complete prior authorization with NF1 diagnosis confirmation, imaging showing symptomatic plexiform neurofibromas, and documentation that surgery isn't feasible. If denied, file an internal appeal within 180 days, then use New Jersey's Independent Health Care Appeals Program (IHCAP) through Maximus for external review. Start today: Call Aetna member services at the number on your card to request the current Koselugo prior authorization form and confirm your plan's specialty pharmacy requirements.

Table of Contents

Understanding Your Aetna CVS Health Denial

When Aetna CVS Health denies Koselugo (selumetinib) coverage, the denial letter will include specific reason codes. Here are the most common reasons and how to address them:

Denial Reason What It Means How to Fix It
Prior authorization required No PA submitted or incomplete Submit complete PA form with all required documentation
Not medically necessary Clinical criteria not met Provide detailed medical necessity letter addressing specific criteria
Step therapy required Must try preferred alternatives first Document failures/contraindications to required step drugs
Non-formulary Drug not on plan's preferred list Request formulary exception with clinical justification
Age restriction Outside approved age range Provide FDA labeling showing pediatric approval (ages 1+ for NF1)
Note: Aetna processes most specialty drugs like Koselugo through CVS Specialty Pharmacy. Verify your prescription is being filled through the correct specialty pharmacy network.

Koselugo Coverage Requirements at a Glance

Requirement Details Documentation Needed Source
Diagnosis NF1 with symptomatic, inoperable plexiform neurofibromas Clinical notes, genetic testing results FDA Koselugo Label
Age Pediatric patients ≥1 year Birth certificate, medical records FDA Approval
Prior authorization Required for all plans Complete Aetna PA form Aetna Precertification List
Prescriber Oncologist or neurologist preferred Provider credentials, specialty certification Plan-specific requirement
Imaging MRI showing plexiform neurofibromas Recent MRI reports with volumetric measurements Clinical standard

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation

Who does it: Patient/family with clinic support
Timeline: 1-2 weeks
Documents needed:

  • Complete medical records confirming NF1 diagnosis
  • Recent MRI reports showing plexiform neurofibromas
  • Clinical notes documenting symptoms and functional impairment
  • Surgical consultation notes (if applicable) stating inoperability

2. Submit Prior Authorization

Who does it: Prescribing physician
How to submit: Aetna provider portal or fax (verify current number with plan)
Timeline: Submit 2-3 weeks before intended start date
Expected response: 15-30 business days for standard review

3. Request Peer-to-Peer Review (If Initially Denied)

Who does it: Prescribing physician
When: Within 24-48 hours of denial
Process: Call Aetna utilization management to schedule discussion with medical director

4. File Internal Appeal

Who does it: Patient, family, or provider with authorization
Deadline: 180 days from denial date
Required: Written appeal letter addressing specific denial reasons

5. External Review Through IHCAP

Who does it: Patient/family
When: After completing Aetna's internal appeal process
Deadline: 4 months (120 days) from final internal denial
Cost: Free to patient

Clinician Corner: Medical Necessity Letter Checklist

When crafting a medical necessity letter for Koselugo, address these key elements:

Patient Background:

  • Confirmed NF1 diagnosis (clinical criteria and/or genetic testing)
  • Age and weight for dosing calculations
  • Current symptoms and functional limitations

Clinical Rationale:

  • Detailed description of plexiform neurofibromas (location, size, symptoms)
  • Documentation that tumors are inoperable (surgical consultation notes)
  • Impact on quality of life, development, or organ function

Treatment History:

  • Previous interventions attempted (surgery, pain management, physical therapy)
  • Outcomes and reasons for discontinuation
  • Contraindications to alternative treatments

Supporting Evidence:

  • FDA approval for pediatric NF1 patients with symptomatic, inoperable plexiform neurofibromas
  • Clinical trial data showing efficacy in tumor volume reduction
  • Guidelines from Children's Tumor Foundation or NF specialist centers
Tip: Include specific measurements from imaging studies and functional assessments to demonstrate objective need for treatment.

New Jersey External Review Through IHCAP

New Jersey's Independent Health Care Appeals Program (IHCAP) provides an excellent opportunity to overturn Aetna denials. The program is now managed by Maximus Federal Services.

Eligibility Requirements

  • Completed Aetna's internal appeal process (typically 2 levels)
  • New Jersey-regulated insurance plan
  • Denial based on medical necessity or similar coverage criteria
  • Appeal filed within 4 months of final internal denial

How to Submit

  1. Contact IHCAP: Call 1-888-393-1062 for guidance
  2. Submit online: Visit Maximus IHCAP portal (verify current link)
  3. Required documents:
    • Completed external review request form
    • All denial letters from Aetna
    • Medical records supporting the appeal
    • Doctor's letter explaining medical necessity

Timeline

  • Preliminary review: 5 business days to determine eligibility
  • Full review: 45 days for standard cases
  • Expedited review: Available when delay could cause serious harm
Important: The external review is binding on Aetna if the decision favors coverage. Success rates for external appeals nationwide average around 40-50%.

Cost-Saving Options While Appealing

Don't let financial concerns delay treatment while your appeal is pending:

Manufacturer Support:

Foundation Support:

  • Children's Tumor Foundation may have resources for NF1 families
  • Patient Advocate Foundation: Offers copay relief programs

State Programs:

  • New Jersey has various pharmaceutical assistance programs for qualifying families

When to Escalate

If your appeals are unsuccessful, consider these escalation options:

File a Complaint with New Jersey DOBI

Contact: NJ Department of Banking and Insurance Consumer Hotline
When to use: If you believe Aetna violated state insurance laws or regulations
Documents to include: All denial letters, appeal responses, and correspondence

Contact Your State Representatives

New Jersey legislators often assist constituents with insurance issues, particularly for rare pediatric conditions.

Media and Advocacy

Patient advocacy groups for NF1 can sometimes provide additional leverage and resources.

Counterforce Health: Streamlining Your Appeal Process

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. The platform identifies the specific denial basis—whether it's prior authorization criteria, step therapy requirements, or "not medically necessary" determinations—and drafts point-by-point responses aligned with Aetna's own coverage rules.

For medications like Koselugo, Counterforce Health pulls the right evidence sources, including FDA labeling, peer-reviewed studies, and specialty guidelines, weaving them into appeals with required clinical facts such as NF1 diagnosis confirmation, prior treatment failures, and treatment goals. This systematic approach helps families and clinicians create cleaner submissions that reduce back-and-forth with payers.

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take for Koselugo in New Jersey? Standard review typically takes 15-30 business days. Expedited review (when delay poses serious health risk) should be completed within 72 hours for urgent cases.

What if Koselugo is non-formulary on my Aetna plan? You can request a formulary exception by demonstrating medical necessity and that formulary alternatives are inappropriate. This requires detailed clinical documentation.

Can I request an expedited appeal if my child's condition is worsening? Yes. Aetna must offer expedited review when delays could seriously jeopardize health. Document any worsening symptoms or functional decline.

Does step therapy apply to pediatric rare disease medications like Koselugo? Step therapy requirements vary by plan. For rare pediatric conditions, you can often obtain exceptions by demonstrating that required step drugs are inappropriate or contraindicated.

What happens if I miss the appeal deadline? Contact Aetna immediately to request an extension. New Jersey law may provide some flexibility for "good cause" delays, especially for pediatric cases.

How much does Koselugo cost without insurance? Cash prices can range from approximately $2,651 for 28×10mg capsules to $6,617 for 28×25mg capsules, though actual costs vary by pharmacy and patient assistance program eligibility.

Can my doctor file the appeal on my behalf? Yes. Providers can file appeals with appropriate patient authorization. Many families find this more effective since doctors can address clinical criteria directly.

What's the success rate for Koselugo appeals in New Jersey? While specific data isn't available, appeals for FDA-approved rare disease medications with strong clinical documentation tend to have higher success rates, particularly at the external review level.

Disclaimer: This guide provides general information about insurance appeals and should not be considered medical or legal advice. Always consult with your healthcare provider about treatment decisions and verify current requirements with your specific Aetna CVS Health plan. Coverage policies and appeal procedures may change.

Need Help? Contact the NJ Department of Banking and Insurance at 1-800-446-7467 for consumer assistance with insurance issues.

Sources & Further Reading

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