By Counterforce Health Team in Imbruvica (ibrutinib) —

Getting Imbruvica (Ibrutinib) Covered by Aetna CVS Health in Virginia: Forms, Appeals, and Step Therapy Rights

Quick Answer: Your Path to Approval

Imbruvica (ibrutinib) requires prior authorization from Aetna CVS Health but no step therapy for CLL/SLL. In Virginia, you have strong appeal rights: 72-hour step therapy override decisions, 180 days to appeal denials, and external review through the State Corporation Commission using Form 216-A. Start today: Have your oncologist submit PA documentation showing FDA-approved indication and any prior treatment failures. If denied, request a peer-to-peer review within 180 days and cite Virginia's medical necessity protections.

Table of Contents

  1. Why Virginia State Rules Matter
  2. Aetna CVS Health Prior Authorization Requirements
  3. Virginia Step Therapy Protections
  4. Appeal Process and Timelines
  5. External Review Through Virginia SCC
  6. Continuity of Care Protections
  7. Practical Scripts and Documentation
  8. When to Contact Virginia Regulators

Why Virginia State Rules Matter

Virginia's insurance laws provide critical protections that work alongside Aetna CVS Health's coverage policies. Unlike federal plans (Medicare, ERISA self-funded), Virginia-regulated commercial plans must follow state requirements for step therapy overrides, appeal timelines, and external review processes.

Key Virginia advantages:

  • 72-hour response time for step therapy exception requests
  • 180-day appeal window (longer than many states)
  • Independent external review with binding decisions
  • Continuity of care protections during provider transitions
Note: If your employer plan is self-funded (ERISA), these Virginia protections may not apply. Check your Summary Plan Description or call member services to confirm.

Aetna CVS Health Prior Authorization Requirements

Coverage at a Glance

Requirement Imbruvica (CLL/SLL) Where to Find It
Prior Authorization Required Aetna policy SGM-1997-A
Step Therapy Not required Same policy
Approval Duration 12 months Same policy
Formulary Status Varies by plan Member ID card or portal
Site of Care Any licensed provider Policy guidelines

Medical Necessity Criteria

Aetna CVS Health will approve Imbruvica for CLL/SLL when prescribed:

  • As single agent therapy
  • In combination with rituximab (with or without bendamustine)
  • With obinutuzumab
  • First-line with venetoclax

Required documentation:

  • FDA-approved or compendia-supported indication
  • Absence of exclusion criteria
  • For reauthorization: no unacceptable toxicity or disease progression

Virginia Step Therapy Protections

Virginia's step therapy law (effective July 2021) requires Aetna CVS Health to grant override requests within 72 hours for standard requests and 24 hours for urgent cases when any of these criteria are met:

Override Criteria

  • Contraindication: The required drug would cause adverse effects or harm
  • Ineffectiveness: Expected to be ineffective based on clinical characteristics
  • Prior failure: Patient tried a drug in the same class and it failed or caused adverse events
  • Not in best interest: Prescriber determines override is medically necessary
  • Current stability: Patient is stable on prescribed therapy with no clinical reason to change

How to Request Override

For patients:

  1. Ask your oncologist to submit a step therapy exception request
  2. Include clinical documentation supporting one of the override criteria above
  3. Mark urgent if delay could harm your health

For clinicians:

  • Submit via Aetna provider portal or precertification line
  • Document specific medical reasons citing Virginia override criteria
  • Include prior treatment history and outcomes
From our advocates: We've seen many BTK inhibitor step therapy requests approved when oncologists clearly document prior treatment failures with specific drugs, dates, and reasons for discontinuation. Be detailed about what was tried and why it didn't work.

Appeal Process and Timelines

Internal Appeals with Aetna CVS Health

Timeline: 180 days from denial notice to file appeal

Standard Appeals:

  • Decision within 30 days for pre-service requests
  • Decision within 60 days for post-service claims

Expedited Appeals:

  • Decision within 72 hours when delay could jeopardize health
  • Available for urgent medical situations

Required Documentation

  • Original denial letter
  • Medical records supporting medical necessity
  • Prescriber letter explaining clinical rationale
  • Evidence of prior treatment failures (if applicable)
  • Current lab results and imaging

Peer-to-Peer Review

Request a peer-to-peer review where your oncologist speaks directly with Aetna's medical director. This often resolves denials faster than written appeals.

External Review Through Virginia SCC

If Aetna CVS Health denies your internal appeal, Virginia's external review process provides an independent second opinion.

Eligibility Requirements

  • Virginia-issued commercial insurance plan
  • Denial based on medical necessity, appropriateness, or experimental/investigational determination
  • Completed Aetna's internal appeal process

How to File External Review

Timeline: 120 days from final denial to submit Form 216-A

Required documents:

Submission options:

  • Mail: State Corporation Commission Bureau of Insurance – External Review, P.O. Box 1157, Richmond, VA 23218
  • Fax: (804) 371-9915
  • Email: [email protected]

External Review Timeline

  • Standard review: Decision within 45 days
  • Expedited review: Decision within 72 hours (with physician certification of urgency)

Contact for help: 1-877-310-6560 (Bureau of Insurance External Review line)

Continuity of Care Protections

Virginia law ensures you won't lose coverage during transitions. If your specialty pharmacy or oncologist leaves Aetna's network while you're receiving active treatment:

Your Rights

  • Continue current treatment for up to 90 days after notification
  • Same benefits, copays, and coverage terms during transition period
  • Provider must accept in-network payment rates during this time

How to Invoke Protection

  1. Contact Aetna CVS Health immediately when notified of network change
  2. Request continuity of care under Virginia law and federal No Surprises Act
  3. Have your oncologist document ongoing active treatment

Practical Scripts and Documentation

Patient Phone Script for Aetna CVS Health

"Hi, I'm calling about a prior authorization denial for Imbruvica for my CLL. My member ID is [number]. I'd like to request a peer-to-peer review with your medical director and my oncologist. Under Virginia law, I also want to ensure we're following proper step therapy override procedures since I've had prior treatment failures. Can you connect me with utilization management?"

Medical Necessity Letter Checklist

For oncologists writing appeals:

  • Patient diagnosis with ICD-10 codes
  • FDA-approved indication for Imbruvica in CLL/SLL
  • Prior treatments tried, dates, and reasons for discontinuation
  • Current disease status and treatment goals
  • Risk-benefit analysis citing clinical guidelines
  • Reference to NCCN Guidelines or other recognized compendia

Common Denial Reasons & Solutions

Denial Reason How to Overturn
"Not medically necessary" Submit detailed clinical notes showing disease progression and treatment rationale
"Experimental/investigational" Provide FDA label and NCCN guideline support for indication
"Non-formulary" Request formulary exception with clinical justification
"Quantity limits exceeded" Document weight-based dosing requirements or clinical need

When to Contact Virginia Regulators

Contact the Virginia Bureau of Insurance if you experience:

  • Delayed responses beyond required timeframes
  • Improper denial of step therapy overrides
  • Failure to provide required appeal rights information
  • Discrimination based on health status

Virginia Bureau of Insurance Consumer Services: 1-877-310-6560

Virginia Managed Care Ombudsman (for Medicaid managed care): 1-800-643-2273

Filing a Complaint

You can file complaints about Aetna CVS Health's handling of your case while pursuing appeals. This doesn't stop your appeal rights but creates regulatory oversight.

Cost-Saving Resources

Even with coverage, Imbruvica can be expensive. Consider these options:

  • AbbVie Patient Assistance: AbbVie.com/patients (verify current programs)
  • Janssen CarePath: Patient support for eligible individuals
  • Virginia Cancer Care Organizations: Contact local cancer centers for foundation grant information
  • Medicare Part D negotiated price: ~$9,319 for 28-day supply starting 2026
Tip: Apply for manufacturer assistance programs before your first fill. Processing can take 2-3 weeks, and retroactive coverage isn't always available.

Limits and Important Caveats

ERISA Plans: If your employer plan is self-funded, Virginia's step therapy and external review protections may not apply. You'll have federal external review rights through HHS instead.

Medicare Plans: Different rules apply for Medicare Advantage and Part D plans. Contact 1-800-MEDICARE for specific guidance.

Medicaid: Virginia Medicaid managed care has separate appeal processes through DMAS Appeals Division (804-371-8488).

FAQ

How long does Aetna CVS Health prior authorization take in Virginia? Standard PA decisions: 15 business days. Expedited requests: 72 hours. Virginia law requires step therapy override decisions within 72 hours.

What if Imbruvica isn't on my formulary? Request a formulary exception with clinical documentation. Aetna CVS Health must review non-formulary requests under the same medical necessity standards.

Can I get an expedited appeal for cancer treatment? Yes. If delay could jeopardize your health, request expedited review. Aetna must decide within 72 hours, and Virginia external review offers 72-hour expedited decisions.

Does step therapy apply if I failed treatments under previous insurance? Virginia law requires Aetna CVS Health to consider prior treatment failures under any insurance when evaluating step therapy overrides.

What happens if my oncologist leaves Aetna's network? You have continuity of care rights for up to 90 days to complete your current treatment course at in-network rates.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters, identifies the specific denial basis, and drafts evidence-backed appeals that address payer requirements point-by-point. For complex cases like Imbruvica appeals, we pull the right clinical evidence—FDA labeling, peer-reviewed studies, and specialty guidelines—and weave them into appeals that meet both medical necessity standards and procedural requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and is not medical or legal advice. Insurance coverage decisions depend on individual circumstances and plan details. Always consult with your healthcare provider about treatment decisions and verify current policy requirements with your insurer. For personalized assistance with appeals, consider working with patient advocacy organizations or Counterforce Health's specialized appeal platform.

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