By Counterforce Health Team in Krystexxa (pegloticase) —

How Long Does It Take to Get Krystexxa (Pegloticase) Approved by Aetna (CVS Health) in Washington? Complete Timeline & Appeal Guide

Answer Box: Getting Krystexxa Approved by Aetna (CVS Health) in Washington

Timeline: Standard prior authorization takes 24-72 hours with complete documentation; expedited reviews for urgent cases complete within 24 hours. Requirements: Age 18+, documented failure of conventional gout therapy (allopurinol/febuxostat), serum uric acid ≤6 mg/dL response, G6PD testing, and methotrexate co-therapy. First step: Contact your rheumatologist to submit the Aetna Specialty Medication Precertification Request form via the provider portal or fax to 1-866-249-6155.

Table of Contents

What Affects Krystexxa Approval Timeline

Several factors influence how quickly Aetna (CVS Health) processes your Krystexxa (pegloticase) prior authorization in Washington:

Benefit Type: Medical benefit coverage (typically faster) vs. specialty pharmacy benefit routing through CVS Caremark can add 1-2 days for coordination.

Documentation Completeness: The most significant factor. Complete submissions with all required clinical documentation, lab results, and specialist attestations process within 24-72 hours. Missing elements trigger information requests that add 3-7 days.

Review Complexity: Straightforward cases meeting all published criteria move fastest. Cases requiring medical director review (e.g., off-label use, incomplete step therapy documentation) may take 5-10 business days.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist

Before submission, gather these required documents to avoid delays:

Clinical Requirements:

  • Serum uric acid (sUA) test results showing levels >6 mg/dL despite conventional therapy
  • G6PD enzyme test results (normal required - contraindication if deficient)
  • Documentation of allopurinol and/or febuxostat trials with doses, duration, and outcomes
  • Chart notes documenting chronic refractory gout with ≥2 flares annually
  • Specialist evaluation (rheumatologist preferred)

Prescription Details:

  • Krystexxa 8 mg IV every 2 weeks dosing plan
  • J2507 billing code (8 units per vial)
  • Infusion site verification (hospital outpatient or infusion center)
  • Methotrexate co-therapy plan with folic acid supplementation
Tip: Contact Aetna member services at the number on your insurance card to verify your specific plan's requirements and confirm CVS Specialty pharmacy coverage.

Submission to Initial Review (1-5 Days)

Washington State Requirements

Washington requires insurers to make prior authorization decisions within specific timeframes:

  • Standard requests: 14 days maximum
  • Expedited requests: 72 hours for urgent medical necessity

Aetna typically processes complete Krystexxa requests faster than state minimums:

  • Standard: 24-72 hours with complete documentation
  • Expedited: 24 hours when prescriber certifies delay would jeopardize health

What Reviewers Check First

Aetna's initial review focuses on these criteria in order:

  1. Age 18+ and chronic refractory gout diagnosis
  2. Documented inadequate response to conventional therapy
  3. G6PD test results (must be normal)
  4. Serum uric acid levels and monitoring plan
  5. Methotrexate co-therapy or documented contraindication
  6. Prescriber qualifications (rheumatologist/nephrologist preferred)

Additional Information Requests (1-7 Days)

If Aetna requests additional information, respond within 14 days to avoid automatic denial. Common requests include:

Missing Lab Results: Submit G6PD test, recent sUA levels, or baseline kidney function tests within 48 hours via fax (1-866-249-6155) or provider portal.

Insufficient Step Therapy Documentation: Provide detailed records of allopurinol/febuxostat trials including specific doses, duration (minimum 3 months at maximum tolerated dose), and reasons for discontinuation.

Specialist Consultation: If prescribed by primary care, obtain rheumatology consultation letter supporting medical necessity.

Note: Counterforce Health can help streamline this process by analyzing denial letters and identifying exactly what additional documentation is needed, reducing back-and-forth delays.

Decision Window & Outcomes

Typical Approval Timeline

  • Complete submission: 1-3 business days
  • Additional info needed: 3-7 business days after response
  • Medical director review: 5-10 business days

Reading Your Approval Letter

Approved requests will specify:

  • Authorized quantity (typically 6-month supply for initial approval)
  • Dispensing pharmacy (CVS Specialty)
  • Prior authorization number for claims processing
  • Reauthorization date

Partial approvals may limit initial quantity to 3 months pending response assessment.

If Denied: Washington Appeal Process

Internal Appeals with Aetna

Level 1 Internal Appeal:

  • Deadline: 180 days from denial notice
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Submit via: Aetna provider portal or mail to address on denial letter
  • Required: Denial letter, additional clinical evidence, medical necessity letter

Level 2 Internal Appeal (if available):

  • Timeline: 30 days from Level 1 denial
  • Process: Automatic physician review for medical necessity denials

Washington External Review Process

After exhausting internal appeals, Washington residents can request independent external review through the Office of the Insurance Commissioner (OIC):

External Review Timeline:

  • Request deadline: 30 days after final internal denial
  • Review timeline: 45 days for standard cases, 72 hours for expedited
  • Cost: Free to consumers
  • Decision: Binding on Aetna if overturned

How to Request:

  1. Submit Form 1300-424 via the Washington OIC portal
  2. Include all denial letters and supporting medical records
  3. Request expedited review if urgent medical necessity
Washington Advantage: The state's strong consumer protection laws and independent review process have helped many patients overturn specialty drug denials, particularly when FDA-approved indications and guideline support are clearly documented.

Renewal Cycles & Reauthorization

Krystexxa reauthorization typically occurs every 6-12 months, depending on your plan. Key requirements for renewal:

Response Documentation:

  • Serum uric acid ≤6 mg/dL on day 14 of two consecutive monthly infusions
  • Reduction in gout flares compared to baseline
  • Tolerability assessment (no severe infusion reactions)

Ongoing Requirements:

  • Continued methotrexate co-therapy with folic acid
  • Regular monitoring by rheumatologist
  • Confirmation that oral urate-lowering therapies remain contraindicated

Renewal Timeline: Submit reauthorization 30 days before expiration to avoid treatment gaps.

Timeline Visual & Milestones

Phase Timeline Key Actions Expected Outcome
Preparation 0-2 days Gather documentation, verify coverage Complete submission package
Initial Review 1-3 days Aetna reviews complete submission Approval or information request
Additional Info 3-7 days Respond to requests, provide missing docs Final determination
Decision 1-5 days Medical director review if needed Approval, denial, or partial approval
If Denied 30-180 days Internal appeals, external review Reversal or final denial
Fulfillment 1-3 days CVS Specialty processes and ships Treatment begins

Time-Saving Tips

Use Digital Submissions: The Aetna provider portal processes requests faster than fax submissions and provides real-time status updates.

Bundle Evidence: Submit all required documentation together rather than piecemeal. Include a cover letter summarizing how you meet each criterion.

Leverage Specialty Pharmacy Integration: CVS Specialty's coordination with Aetna can expedite processing when submissions route directly through their integrated system.

Consider Peer-to-Peer: For complex cases, request a peer-to-peer review with Aetna's medical director early in the process rather than waiting for denial.

Track Deadlines: Use calendar reminders for reauthorization dates and appeal deadlines to avoid treatment interruptions.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Insufficient step therapy Document specific trials with doses/duration Pharmacy records, chart notes showing allopurinol ≥300mg daily x3 months
Missing G6PD test Order and submit normal G6PD result Lab report from CLIA-certified laboratory
Serum uric acid not documented Provide baseline and monitoring labs sUA >6 mg/dL despite therapy, monitoring plan
No methotrexate plan Add MTX co-therapy or document contraindication Prescription for MTX + folic acid or medical contraindication letter
Non-specialist prescriber Obtain rheumatology consultation Specialist evaluation supporting Krystexxa necessity

FAQ

How long does Aetna (CVS Health) prior authorization take in Washington? Standard requests with complete documentation typically process within 24-72 hours. Expedited requests for urgent medical necessity are decided within 24 hours.

What if Krystexxa is non-formulary on my plan? You can request a formulary exception with medical necessity documentation. The process follows the same timeline as prior authorization but may require additional clinical justification.

Can I request an expedited appeal in Washington? Yes, if your prescriber certifies that delay would jeopardize your health. Expedited appeals must be decided within 72 hours for internal review.

Does step therapy apply if I tried medications outside Washington? Yes, documented trials from any location count toward step therapy requirements. Provide pharmacy records and clinical notes from your previous providers.

What happens if I miss the appeal deadline? Washington allows 180 days for internal appeals from the denial date. If you miss this deadline, you may need to submit a new prior authorization request.

How often do I need reauthorization for Krystexxa? Typically every 6-12 months, depending on your plan. Submit renewal requests 30 days before expiration to avoid treatment gaps.

Can Counterforce Health help with my Krystexxa appeal? Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. The platform can analyze your denial letter and draft a point-by-point rebuttal aligned with Aetna's specific criteria and Washington's appeal requirements.

From Our Advocates: We've seen cases where patients initially denied for Krystexxa received approval on appeal by providing more detailed documentation of their allopurinol trial, including the specific dose escalation attempted and documented intolerance symptoms. The key was showing the prescriber had optimized conventional therapy before requesting the specialty medication.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and procedures may change. Always verify current requirements with your insurer and consult your healthcare provider for medical decisions.

For additional help with insurance appeals in Washington, contact the Office of the Insurance Commissioner Consumer Advocacy line at 1-800-562-6900 or visit insurance.wa.gov.

Sources & Further Reading

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