By Counterforce Health Team in Oxbryta (voxelotor) —

Getting Oxbryta (Voxelotor) Covered by Aetna CVS Health in Virginia: 2024 Updates, Appeals, and Alternatives

Quick Answer: Oxbryta Coverage Status in Virginia

Important Update: Oxbryta (voxelotor) is no longer FDA-approved in the United States as of 2024. Pfizer withdrew the drug following a confirmatory evidence review. If you're in Virginia with Aetna CVS Health coverage and need sickle cell disease treatment, focus on currently approved alternatives like hydroxyurea, L-glutamine, or crizanlizumab. Your first step: contact your hematologist to discuss transition options and have them initiate prior authorization for an appropriate alternative through Aetna's specialty pharmacy network.

Table of Contents

  1. Current Status of Oxbryta (Voxelotor)
  2. Alternative Sickle Cell Treatments Covered by Aetna
  3. Aetna CVS Health Coverage Requirements
  4. Step-by-Step: Getting Alternative Treatment Approved
  5. Appeals Process in Virginia
  6. Cost Considerations and Assistance Programs
  7. Virginia-Specific Appeal Rights
  8. Scripts for Calling Aetna and Providers
  9. FAQ

Current Status of Oxbryta (Voxelotor)

Oxbryta (voxelotor) was voluntarily withdrawn from the U.S. market by Pfizer in 2024 following an FDA request. The withdrawal came after a confirmatory study failed to demonstrate the expected clinical benefit for sickle cell disease patients. This means:

  • No new prescriptions can be filled in the United States
  • Existing prescriptions are no longer covered by insurance
  • Claims will be denied due to loss of FDA approval
Note: The drug may still be available in other countries where regulatory approval remains in place, but U.S. patients need alternative treatments.

Alternative Sickle Cell Treatments Covered by Aetna

Aetna CVS Health covers several FDA-approved treatments for sickle cell disease:

First-Line Therapies

  • Hydroxyurea (Droxia, Hydrea, Siklos) - Oral medication that reduces pain crises
  • L-glutamine (Endari) - Oral powder that may reduce complications

Advanced Therapies

  • Crizanlizumab (Adakveo) - IV infusion to reduce vaso-occlusive crises
  • Voxelotor alternatives under development - Consult your hematologist

Coverage Requirements Table

Treatment Prior Authorization Specialty Pharmacy Typical Copay
Hydroxyurea Usually not required No $20-$75
L-glutamine Required Yes (CVS Specialty) $250 per fill
Crizanlizumab Required Yes (CVS Specialty) $250 per fill

Source: Aetna 2024 Specialty Drug List

Aetna CVS Health Coverage Requirements

Prior Authorization Criteria

For specialty sickle cell medications, Aetna typically requires:

  • Confirmed diagnosis of sickle cell disease with appropriate lab values
  • Documentation of disease severity (frequency of crises, hospitalizations)
  • Trial of standard therapy (usually hydroxyurea) unless contraindicated
  • Prescriber specialty (hematologist or sickle cell specialist preferred)

Formulary Status

Most sickle cell treatments are placed on Aetna's specialty tier, requiring:

  • CVS Specialty Pharmacy dispensing
  • Higher copays ($250 per prescription typically)
  • Enhanced monitoring and patient support services

Step-by-Step: Getting Alternative Treatment Approved

1. Consult Your Hematologist

  • Who: Patient schedules appointment
  • Timeline: Within 2-4 weeks
  • Document needed: Recent lab work, crisis history
  • Next step: Discuss Oxbryta alternatives and treatment goals

2. Obtain Prior Authorization

  • Who: Prescriber submits PA request
  • Timeline: 72 hours for standard, 24 hours for urgent
  • Documents needed: Clinical notes, lab results, prior therapy history
  • Submit via: Aetna provider portal or fax

3. Benefits Investigation

  • Who: Patient or clinic staff calls Aetna
  • Phone: Member services number on insurance card
  • Ask about: Copay, deductible, specialty pharmacy requirements
  • Record: Reference number, representative name, coverage details

4. Specialty Pharmacy Coordination

  • Who: CVS Specialty Pharmacy contacts patient
  • Timeline: Within 5-7 business days of approval
  • Services: Copay assistance enrollment, delivery coordination
  • Contact: CVS Specialty Pharmacy

Appeals Process in Virginia

Internal Appeals with Aetna

If your alternative treatment is denied:

Standard Appeal Timeline:

  • Deadline to file: 180 days from denial notice
  • Aetna decision time: 30 days for standard, 72 hours for expedited
  • Required: Written request with supporting clinical documentation

Expedited Appeals:

  • When to request: If delay could harm your health
  • Timeline: 72 hours for decision
  • Certification: Doctor must confirm urgency

External Review in Virginia

After exhausting internal appeals, Virginia residents have additional rights:

Virginia State Corporation Commission External Review:

  • Deadline: 120 days from final internal denial
  • Timeline: 45 days for standard, 72 hours for expedited
  • Forms: Form 216-A External Review Request
  • Cost: Free to consumers
  • Contact: (877) 310-6560
Virginia Advantage: The state allows direct external review for cancer treatment denials without completing internal appeals first - a unique protection for urgent cases.

Cost Considerations and Assistance Programs

Manufacturer Copay Programs

  • Eligibility: Commercial insurance (not Medicare/Medicaid)
  • Savings: Often reduce copay to $10-$25 per prescription
  • Enrollment: Through CVS Specialty or manufacturer websites

Foundation Assistance

  • Sickle Cell Disease Association of America - Patient assistance programs
  • HealthWell Foundation - Copay assistance for qualifying patients
  • Patient Access Network Foundation - Disease-specific grants

Aetna-Specific Programs

  • PrudentRx Program - May reduce specialty drug costs to $0 for eligible members
  • Case management - Available for complex conditions like sickle cell disease

Virginia-Specific Appeal Rights

Virginia provides robust consumer protections for health insurance denials:

State Corporation Commission Bureau of Insurance

  • Role: Oversees external review process
  • Authority: Can overturn insurer denials with binding decisions
  • Support: Free guidance on appeal process

Managed Care Ombudsman

  • Service: Informal resolution of health plan disputes
  • Contact: Through SCC Consumer Services
  • Benefit: Can sometimes resolve issues without formal appeals

Virginia Poverty Law Center

  • Service: Legal assistance for healthcare access issues
  • Focus: Medicaid and ACA marketplace problems
  • Cost: Free for qualifying patients

Scripts for Calling Aetna and Providers

Calling Aetna Member Services

"Hi, I'm calling about coverage for sickle cell disease treatment. My doctor wants to prescribe [alternative drug name] since Oxbryta is no longer available. Can you tell me:

  • Is this drug covered on my plan?
  • What's my copay?
  • Is prior authorization required?
  • Do I need to use CVS Specialty Pharmacy?"

Requesting Peer-to-Peer Review

"I'm calling to request a peer-to-peer review for my patient's denied [drug name] prior authorization. The patient has sickle cell disease and needs this treatment because [brief clinical reason]. When can our hematologist speak with your medical director?"

Following Up on Appeals

"I'm calling about my appeal reference number [number]. It's been [X days] since I submitted it. Can you provide a status update and confirm you received all my supporting documents?"

FAQ

Q: Can I still get Oxbryta if I was already taking it? A: No, Oxbryta is no longer available in the United States. Your doctor needs to transition you to an FDA-approved alternative.

Q: How long does Aetna take to approve alternative treatments? A: Standard prior authorizations are decided within 72 hours. Expedited requests for urgent cases are decided within 24 hours.

Q: What if my doctor says I need a specific alternative that Aetna doesn't cover? A: Request a formulary exception with detailed medical justification. If denied, appeal through Aetna's process and then Virginia's external review.

Q: Does step therapy apply if I was already on Oxbryta? A: Possibly. Aetna may still require trial of first-line therapies like hydroxyurea unless your doctor documents contraindications or previous failures.

Q: Can I appeal directly to Virginia without going through Aetna first? A: Generally no, except for certain cancer treatment denials. You must complete Aetna's internal appeal process first.

Q: Are there clinical trials available for new sickle cell treatments? A: Yes, consult with your hematologist about ongoing trials. ClinicalTrials.gov lists current studies.

Q: What happens if I can't afford my copay for alternative treatments? A: Explore manufacturer copay programs, foundation grants, and Aetna's case management services for financial assistance options.

Q: How do I find a sickle cell specialist in Virginia? A: Contact the Sickle Cell Disease Association of America for provider referrals in your area.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex insurance approvals by turning denials into targeted, evidence-backed appeals. The platform analyzes denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with payer requirements, pulling the right medical citations and clinical facts to support coverage requests.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment options and your insurance company about coverage details. For official Virginia insurance regulations and appeal procedures, visit the State Corporation Commission Bureau of Insurance.

Sources & Further Reading

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