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

Getting Eylea and Lucentis Covered by Aetna CVS Health in Ohio: Complete Prior Authorization Guide

Quick Answer: Getting Eylea/Lucentis Approved by Aetna CVS Health in Ohio

Fastest path to approval: Submit prior authorization through your retinal specialist with current OCT imaging, visual acuity measurements, and documented diagnosis (wet AMD, diabetic macular edema, or retinal vein occlusion). Aetna typically requires 12 months of clinical documentation and may mandate step therapy with bevacizumab first. Standard decisions take 30-45 days; expedited reviews (for urgent vision loss) complete within 72 hours. If denied, Ohio residents have 180 days to request external review through an Independent Review Organization.

Start today: Contact your ophthalmologist to request prior authorization and ensure all required clinical documentation is current.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required before treatment Aetna 2025 Precertification List
Formulary Status Tier 3-4 specialty drugs Member portal or formulary guide
Step Therapy May require bevacizumab trial first Plan-specific policy documents
Diagnosis Codes ICD-10: H35.32 (wet AMD), E11.311 (diabetic macular edema) Clinical documentation
Imaging Requirements OCT within 30-60 days showing disease activity Ophthalmology records
Authorization Duration 6-12 months typically Approval letter specifications

Step-by-Step: Fastest Path to Approval

1. Confirm Your Diagnosis and Treatment History

Who does it: Your retinal specialist
Timeline: Same day as consultation
Required: Document specific diagnosis with ICD-10 codes and any prior anti-VEGF treatments attempted.

2. Gather Current Clinical Evidence

Who does it: Ophthalmology clinic staff
Timeline: 1-2 business days
Required:

  • OCT scan within 30-60 days showing persistent disease activity
  • Current visual acuity measurements (Snellen or ETDRS)
  • Comparison with baseline imaging and prior treatment response

3. Submit Prior Authorization Request

Who does it: Your prescriber's office
How to submit: CVS Caremark provider portal or fax to specialty pharmacy team
Timeline: Allow 30-45 days for standard review, 72 hours for expedited

Tip: Request expedited review if any delay could worsen vision loss or delay critical treatment.

4. Include Complete Medical Necessity Letter

Who does it: Your ophthalmologist
Required elements: Specific diagnosis, treatment goals, why alternatives aren't appropriate, and supporting clinical guidelines
Timeline: Should accompany initial PA request

5. Monitor Authorization Status

Who does it: Patient and clinic staff
How: Aetna member portal or provider portal
Timeline: Check status after 15 days for standard requests

6. If Denied, File Internal Appeal Immediately

Who does it: Patient or authorized representative
Timeline: Must file within 180 days of denial notice
Required: Additional clinical evidence, peer-to-peer review request if applicable

7. Request External Review if Internal Appeal Fails

Who does it: Patient
Timeline: Within 180 days of final internal denial
Process: Independent Review Organization makes binding decision

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Step therapy not completed Document bevacizumab failure/intolerance Prior treatment records, adverse event notes, lack of response data
Insufficient imaging evidence Submit current OCT with comparison OCT within 30 days, baseline comparison, disease activity markers
Non-formulary status Request formulary exception Medical necessity letter, clinical guideline citations
Quantity/frequency limits Justify loading dose schedule FDA labeling, clinical protocol, treatment response monitoring
"Not medically necessary" Strengthen clinical documentation Updated visual acuity, anatomic evidence, functional impact assessment

According to recent research, step therapy requirements account for 76% of anti-VEGF prior authorization denials, making documentation of prior treatment failures critical for approval.

Medical Necessity Letter Requirements

Clinician Corner: Essential Documentation Elements

Your ophthalmologist's medical necessity letter should include:

Clinical Problem Statement:

  • Specific diagnosis with ICD-10 codes
  • Disease severity and progression
  • Impact on visual function and daily activities

Prior Treatment History:

  • Previous anti-VEGF agents tried (if any)
  • Duration of treatment and response
  • Reasons for discontinuation or inadequacy
  • Documentation of bevacizumab trial (if required by step therapy)

Clinical Rationale:

  • Why Eylea or Lucentis is medically necessary
  • Expected treatment outcomes and monitoring plan
  • Contraindications to alternative treatments

Supporting Evidence:

  • FDA prescribing information for approved indications
  • Current clinical guidelines from American Academy of Ophthalmology
  • Peer-reviewed literature supporting treatment choice
Note: Include specific visual acuity measurements and OCT findings with quantitative measures when possible.

Appeals Process in Ohio

Internal Appeals with Aetna CVS Health

First Level Appeal:

  • Timeline: File within 180 days of denial
  • Decision timeframe: 30 days for standard, 72 hours for expedited
  • How to file: Written request to address on denial letter
  • Required: Additional clinical evidence, updated medical necessity letter

Peer-to-Peer Review:

  • When to request: If clinical criteria questions arise
  • Who participates: Your ophthalmologist and Aetna medical director
  • Timeline: Usually scheduled within 1-2 business days
  • Preparation: Have current imaging, treatment history, and guidelines ready

External Review in Ohio

If Aetna upholds their denial after internal appeals, Ohio residents can request an independent external review through an Independent Review Organization (IRO).

Key Details:

To Request External Review:

  1. Submit written request to Aetna (contact info on denial letter)
  2. Include all relevant medical records
  3. Ohio Department of Insurance assigns IRO with medical experts
  4. IRO reviews case independently and issues binding decision
Important: The IRO decision is final and binding on your insurance company.

Cost-Saving Options

While working through the approval process, explore these cost-reduction strategies:

Manufacturer Support Programs:

  • Eylea: Regeneron offers copay assistance and patient support programs
  • Lucentis: Genentech Access Solutions provides financial assistance options
  • Eligibility: Typically for commercially insured patients, income restrictions may apply

Specialty Pharmacy Benefits:

  • Aetna partners with CVS Specialty for these medications
  • May offer lower copays than retail pharmacies
  • Automatic refill coordination with your ophthalmologist

Foundation Assistance:

  • Patient Advocate Foundation
  • NeedyMeds prescription assistance programs
  • Disease-specific foundations for retinal conditions

When to Escalate

Contact the Ohio Department of Insurance Consumer Services Division at 1-800-686-1526 if:

  • Aetna refuses to process your external review request
  • Appeal deadlines are not being met
  • You need help understanding your appeal rights
  • The insurer is not following Ohio's external review requirements

For Medicaid managed care plans, contact the Ohio Department of Medicaid for state fair hearing requests.

Getting Professional Help

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to draft evidence-backed rebuttals. Their platform identifies specific denial reasons and creates targeted appeals aligned with each payer's requirements, including the operational details and clinical documentation that payers expect for anti-VEGF therapies.

From our advocates: In a recent composite case, a wet AMD patient initially denied for Eylea due to "insufficient step therapy documentation" achieved approval after we helped compile bevacizumab treatment records from three different providers and demonstrated inadequate response with quantitative OCT measurements. The key was organizing scattered medical records into a clear treatment timeline that met Aetna's step therapy requirements.

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take in Ohio? Standard prior authorization decisions take 30-45 days. Expedited reviews for urgent cases are completed within 72 hours when delay could seriously endanger your health.

What if Eylea or Lucentis is non-formulary on my plan? You can request a formulary exception by submitting a medical necessity letter explaining why formulary alternatives are inappropriate for your condition.

Can I request an expedited appeal if my vision is worsening? Yes. Ohio allows expedited external review within 72 hours if delays could seriously jeopardize your health or ability to regain maximum function.

Does step therapy apply if I've already tried bevacizumab outside Ohio? Yes, but you must provide documentation of the prior treatment, including dates, doses, response, and reasons for discontinuation.

What happens if the external review denies my appeal? The IRO decision is final for the external review process, but you retain other rights such as regulatory complaints or legal action if appropriate.

How do I find an Aetna network retinal specialist in Ohio? Use the Aetna provider directory and filter for ophthalmology/retinal specialists. Major Ohio health systems with Aetna contracts include Cleveland Clinic, Ohio State Wexner Medical Center, and Cincinnati Eye Institute.

Will Aetna cover both loading doses and maintenance injections? Yes, when medically necessary and properly documented. Authorization typically covers the full treatment protocol including monthly loading doses followed by extended maintenance schedules.

Can my doctor request a peer-to-peer review during the initial prior authorization? Yes, peer-to-peer reviews can be requested at any stage when clinical questions arise. These discussions between your ophthalmologist and Aetna's medical director often resolve coverage issues quickly.

Disclaimer: This information is for educational purposes and does not constitute medical advice. Coverage decisions depend on your specific plan terms and clinical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance.

Sources & Further Reading

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