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

How Long Does It Take to Get Eylea or Lucentis Approved by Aetna (CVS Health) in Illinois? Complete Timeline Guide

Answer Box: Fast Track to Approval

Getting Eylea or Lucentis approved by Aetna (CVS Health) in Illinois typically takes 14 calendar days for standard prior authorization, or 24 hours for expedited reviews. Both medications require prior authorization with OCT imaging, visual acuity documentation, and diagnosis confirmation. Start by having your ophthalmologist submit a complete PA request through Aetna's provider portal with all required clinical documentation. If denied, you have 180 days to appeal internally, then can request Illinois external review within 4 months of the final denial.

First step today: Call your eye doctor to verify they have recent OCT scans, fluorescein angiography results, and visual acuity measurements ready for the PA submission.

Table of Contents

  1. What Affects Approval Timing
  2. Pre-Submission Preparation (0-2 Days)
  3. Submission to Initial Review (1-5 Days)
  4. Additional Information Requests (1-7 Days)
  5. Decision Window & Outcomes
  6. If Denied: Appeal Timeline
  7. Renewal Cycles & Maintenance
  8. Complete Timeline Visual
  9. Time-Saving Tips
  10. FAQ

What Affects Approval Timing

Several factors influence how quickly Aetna (CVS Health) approves Eylea (aflibercept) or Lucentis (ranibizumab) in Illinois:

Benefit Type Matters

  • Commercial plans: Standard 14-day review through CVS Caremark specialty pharmacy
  • Medicare Advantage: Same timeline but subject to CMS coverage policies
  • Illinois Medicaid (Aetna Better Health): Prior authorization required with similar processing times

Documentation Completeness Your approval speed depends heavily on submitting complete clinical evidence upfront:

  • Recent OCT imaging showing retinal pathology
  • Best-corrected visual acuity measurements for both eyes
  • Fluorescein angiography demonstrating active disease
  • Clear diagnosis with appropriate ICD-10 codes
  • Prior treatment history and response documentation

Medical Urgency If your vision loss is progressing rapidly, mark requests as "expedited" or "urgent." Aetna processes urgent requests within 24 hours in over 95% of cases.

Note: Illinois law requires insurers to decide pre-service appeals within 15 business days, which is stricter than federal requirements.

Pre-Submission Preparation (0-2 Days)

Essential Documents Checklist

Before your ophthalmologist submits the prior authorization, gather:

Clinical Documentation

  • Comprehensive eye exam notes (within 30 days)
  • OCT scans showing subretinal/intraretinal fluid or macular edema
  • Fluorescein angiography results documenting active leakage
  • Visual acuity measurements (ETDRS or Snellen for both eyes)
  • Previous treatment records and outcomes

Administrative Requirements

  • Current Aetna member ID and policy information
  • Prescriber's NPI and taxonomy codes
  • Appropriate diagnosis codes (wet AMD: H35.32; diabetic macular edema: E11.311)
  • NDC numbers for specific Eylea/Lucentis formulations

Coverage Verification

Call Aetna member services at 1-888-632-3862 to confirm:

  • Prior authorization requirement status
  • Formulary tier placement
  • Any step therapy requirements (typically bevacizumab first-line)
  • Copay responsibilities

Submission to Initial Review (1-5 Days)

How Providers Submit

Ophthalmologists can submit PA requests through multiple channels:

  • Availity provider portal (fastest processing)
  • CVS Caremark Novologix for specialty medications
  • Direct fax: 1-877-779-5234 for medical benefit drugs
  • Phone: 1-888-632-3862 for urgent requests
Tip: Electronic submissions through Availity typically process 1-2 days faster than fax submissions.

What Reviewers Check First

Aetna's clinical reviewers immediately assess:

  1. Diagnosis alignment with FDA-approved indications
  2. Visual acuity documentation showing functional impairment
  3. OCT evidence of active retinal disease
  4. Step therapy compliance (bevacizumab trial if required)
  5. Dosing appropriateness per label recommendations

Illinois-Specific Timeline: Under Illinois insurance law, Aetna must acknowledge receipt within 2 business days and provide a decision within 15 business days for pre-service requests.

Additional Information Requests (1-7 Days)

If Aetna requests more information, they'll contact the prescribing physician directly. Common requests include:

Missing Clinical Data

  • More recent OCT scans if submitted imaging is over 60 days old
  • Detailed prior treatment history with specific dates and outcomes
  • Visual field testing results
  • Contraindication documentation for step therapy alternatives

Responding Quickly

When your doctor receives an information request:

  • Same-day response: Fax additional documents to the number provided
  • Portal upload: Use Availity for fastest processing
  • Phone clarification: Call the reviewer directly if contact info is provided
Important: Information requests pause the review clock. Quick responses prevent delays that could extend approval by weeks.

Decision Window & Outcomes

Typical Approval Timeline

Request Type Standard Timeline Expedited Timeline
Initial PA Up to 14 calendar days Within 24 hours
Additional info response 5-7 business days Same day
Reauthorization 7-10 business days Within 24 hours

Reading Your Approval Letter

Approved requests include:

  • Specific NDC codes covered
  • Quantity limits per fill/month
  • Duration of authorization (typically 6-12 months)
  • Site of care restrictions (if any)

Conditional approvals may require:

  • Regular OCT monitoring every 3-6 months
  • Visual acuity assessments before each injection
  • Response documentation for continued coverage

If Denied: Appeal Timeline

Illinois Appeal Rights

Under Illinois law, you have strong appeal protections:

Internal Appeals with Aetna

  • Timeline to file: 180 days from denial date
  • Aetna's decision deadline: 15 business days (30 days federal maximum)
  • Expedited appeals: 24 hours if delay risks health

External Review Process If Aetna doesn't respond within 30 days OR if they deny your internal appeal:

  • File external review: Within 4 months of final denial
  • Illinois Department of Insurance: Assigns independent physician reviewer
  • Decision timeline: 5 business days after reviewer receives all records
  • Cost: Free to patients; insurers pay review fees
Critical Deadline: Illinois' 30-day window for external review requests is shorter than many states. Don't wait—file promptly after internal appeal denial.

Appeal Success Strategies

Strengthen Your Case

  • Include peer-reviewed studies supporting off-label use (if applicable)
  • Obtain letters from retinal specialists confirming medical necessity
  • Document functional vision improvements from prior anti-VEGF therapy
  • Reference FDA labeling for approved indications

Illinois Resources for Help

  • Illinois Department of Insurance: 877-527-9431
  • Illinois Attorney General Health Care Helpline: 877-305-5145
  • Counterforce Health: Specialized platform that helps turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and drafting point-by-point rebuttals aligned to payer policies.

Renewal Cycles & Maintenance

When to Reauthorize

Most Eylea/Lucentis authorizations require renewal every 6-12 months. Submit renewal requests:

  • 30 days before expiration to avoid treatment gaps
  • Immediately if injection frequency changes
  • After any significant clinical changes (new eye involvement, treatment response changes)

Documentation for Renewals

Required for Continued Coverage

  • Follow-up OCT scans showing treatment response or ongoing disease activity
  • Visual acuity trends over treatment period
  • Injection log with dates and responses
  • Physician assessment of ongoing medical necessity

What Speeds Renewals

  • Consistent treatment response documentation
  • Regular monitoring compliance
  • Clear treatment goals and progress notes

Complete Timeline Visual

Standard Approval Process

Day 0: Complete PA submission
↓
Days 1-2: Aetna acknowledges receipt
↓
Days 3-7: Clinical review begins
↓
Days 8-14: Decision issued
↓
Day 15+: If denied, internal appeal window opens (180 days)

Expedited Process (Urgent Cases)

Day 0: Submit urgent PA request
↓
Hours 1-6: Aetna clinical review
↓
Hours 12-24: Decision issued
↓
Immediate: Treatment can begin if approved

Time-Saving Tips

For Patients

Before Your Appointment

  • Bring complete insurance card and prior treatment records
  • List all previous eye medications and responses
  • Prepare questions about injection schedule and monitoring

During Prior Authorization

  • Stay in close contact with your ophthalmologist's office
  • Respond immediately to any information requests
  • Consider Counterforce Health's appeal assistance if initially denied

For Providers

Streamline Submissions

  • Use Availity portal for fastest processing
  • Submit complete documentation packages upfront
  • Include specific ICD-10 codes: H35.32 (wet AMD), E11.311 (diabetic macular edema)
  • Reference Aetna's clinical policy bulletins when documenting medical necessity

Bundle Supporting Evidence

  • OCT reports with measurements and interpretations
  • Fluorescein angiography with active leakage documentation
  • Prior treatment timelines with specific outcomes
  • Visual acuity logs showing functional impact

FAQ

How long does Aetna take for Eylea/Lucentis prior authorization in Illinois? Standard requests: up to 14 calendar days. Expedited/urgent requests: within 24 hours. Illinois law requires decisions within 15 business days for pre-service requests.

What if Eylea or Lucentis isn't on Aetna's formulary? Both medications typically require prior authorization but are covered for FDA-approved ophthalmic indications. Non-formulary status may require formulary exception requests with additional documentation.

Can I request an expedited appeal if my vision is worsening? Yes. Mark requests as "urgent" if delay could seriously jeopardize your health. Aetna must respond within 24 hours for expedited appeals, and Illinois external reviews can be completed in 24-72 hours for urgent cases.

Does step therapy apply if I've used anti-VEGF therapy before? Previous use of Eylea/Lucentis within 365 days typically exempts you from step therapy requirements. Document prior treatment dates and responses clearly.

What happens if I miss the Illinois external review deadline? Illinois requires external review requests within 4 months of final internal appeal denial. Missing this deadline eliminates your right to independent review, so file promptly.

How much will I pay out-of-pocket? Costs vary by plan. Check manufacturer copay assistance programs: Eylea Savings Program and Lucentis patient support. Some Illinois residents may qualify for additional state pharmaceutical assistance programs.

Counterforce Health helps patients navigate complex insurance appeals by analyzing denial letters and crafting evidence-backed responses that align with each payer's specific policies. Their platform specializes in turning insurance denials into successful approvals through targeted documentation and clinical evidence compilation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances and plan specifics. Always consult with your healthcare provider and insurance company for personalized guidance. For assistance with complex appeals, consider professional advocacy services like Counterforce Health.

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