By Counterforce Health Team in Alecensa (alectinib) —

How to Get Alecensa (Alectinib) Covered by Aetna CVS Health in New Jersey: Complete Guide to Prior Authorization and Appeals

Answer Box: Getting Alecensa Covered by Aetna CVS Health in New Jersey

Yes, Aetna covers Alecensa (alectinib) for ALK-positive NSCLC with prior authorization. The fastest path to approval requires three essentials: confirmed ALK-positive test results, a comprehensive medical necessity letter from your oncologist, and electronic submission through CVS Caremark's portal. Most approvals come within 5-7 business days for standard requests, or 72 hours for expedited cases. Start today by gathering your ALK pathology report and contacting your oncologist's office to initiate the prior authorization process.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timing and Deadlines
  4. Medical Necessity Criteria
  5. Costs and Financial Assistance
  6. Denials and Appeals Process
  7. Specialty Pharmacy Requirements
  8. New Jersey External Review Rights
  9. Frequently Asked Questions

Coverage Basics

Is Alecensa Covered by Aetna CVS Health?

Aetna covers Alecensa as a specialty medication for patients with ALK-positive non-small cell lung cancer (NSCLC), including both metastatic and adjuvant (post-surgical) settings. The drug requires prior authorization and is typically dispensed through CVS Specialty Pharmacy or other in-network specialty pharmacies.

Which Aetna Plans Cover Alecensa?

Most Aetna commercial plans in New Jersey cover Alecensa, though specific copay amounts and prior authorization requirements may vary by plan design. New Jersey Aetna Exchange plans include Alecensa on their formularies with specialty tier coverage.

Note: Medicare Advantage and self-funded employer plans may have different coverage rules and appeal processes than those described here.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Confirm ALK-Positive Status (Day 1)
    • Your oncologist must have documented ALK-positive test results
    • This is mandatory for all Alecensa approvals
  2. Gather Required Documentation (Day 1-2)
    • Complete pathology report showing ALK rearrangement
    • Medical necessity letter from your oncologist
    • Prior therapy records (if applicable)
    • Current staging and imaging results
  3. Submit Electronic Prior Authorization (Day 2-3)
  4. Track Your Request (Day 3-7)
    • Standard decisions: 5-7 business days
    • Expedited requests: 72 hours with medical urgency

Required Documentation Checklist

  • ALK-positive pathology report (FDA-approved test)
  • Medical necessity letter citing NCCN guidelines
  • Complete diagnosis with staging information
  • Prior therapy history and outcomes
  • Current medication list
  • Prescriber attestation for dosing requirements

Timing and Deadlines

Request Type Aetna Decision Timeline How to Request
Standard PA 5-7 business days Electronic portal or fax
Expedited PA 72 hours Call member services with urgency documentation
Internal Appeal 7 calendar days Phone: 1-844-362-0934
External Review 45 calendar days New Jersey IHCAP through Maximus

Medical Necessity Criteria

Clinician Corner: Medical Necessity Letter Essentials

Your oncologist's letter should include:

  • ALK-positive NSCLC diagnosis with staging (metastatic vs. adjuvant)
  • NCCN guideline citations supporting Alecensa as category 1 treatment
  • Prior therapy documentation if step therapy applies
  • Clinical rationale for why Alecensa is appropriate
  • Treatment goals and monitoring plan
  • Contraindications to alternative ALK inhibitors (if applicable)

Common Approval Criteria

Aetna typically approves Alecensa when:

  • ALK-positive status is confirmed by FDA-approved testing
  • Patient has metastatic or resected ALK-positive NSCLC
  • 12-month authorization periods are granted for covered indications
  • No evidence of unacceptable toxicity or disease progression for renewals

Costs and Financial Assistance

Out-of-Pocket Costs

Specific copay amounts vary by your Aetna plan design. Alecensa is classified as a specialty medication, typically resulting in higher cost-sharing than standard prescriptions.

Manufacturer Assistance Programs

  • Genentech Oncology Co-pay Assistance: Eligible patients with commercial insurance may pay as little as $0 per treatment
  • Genentech Patient Foundation: Free medication for uninsured patients meeting financial criteria
  • Programs are not available for Medicare, Medicaid, or government-funded insurance
Tip: Apply for manufacturer assistance before your first fill to maximize savings.

Denials and Appeals Process

Common Denial Reasons & Solutions

Denial Reason How to Overturn
Missing ALK test results Submit complete pathology report with ALK rearrangement confirmation
Step therapy not met Document prior ALK inhibitor failure or intolerance with clinical notes
Not medically necessary Strengthen medical necessity letter with NCCN guideline citations
Non-formulary status Request formulary exception with prescriber attestation
Quantity limit exceeded Include clinical rationale for specific dosing requirements

Aetna Internal Appeals Process

If your prior authorization is denied:

  1. File Internal Appeal (within 60 days)
    • Phone: 1-844-362-0934 (8 AM-8 PM, 7 days/week)
    • Online: Complete redetermination form in member portal
    • Decision timeline: 7 calendar days
  2. Request Peer-to-Peer Review
    • Include specific request for peer review on appeal form
    • Allows direct physician-to-physician discussion
  3. Expedited Appeals (if medically urgent)
    • 72-hour decision timeline
    • Your doctor must attest that standard timing could cause serious harm

New Jersey External Review Rights

If Aetna upholds their denial after internal appeal, New Jersey residents have strong external review protections through the Independent Health Care Appeals Program (IHCAP).

IHCAP Process Through Maximus

How to File External Review

Submit your appeal to Maximus Federal Services:

  • Complete external appeal application form
  • Include Aetna's internal appeal decision letters
  • Authorization for medical records release
  • Do not send original documents
Important: IHCAP only applies to fully-insured plans regulated by New Jersey. Medicare Advantage and self-funded employer plans follow federal appeal processes.

Specialty Pharmacy Requirements

Alecensa is covered as an outpatient specialty medication, meaning you'll typically fill it through:

  • CVS Specialty Pharmacy (Aetna's preferred specialty pharmacy)
  • Other in-network specialty pharmacies
  • Verify your specific network before filling

Contact your plan to confirm which specialty pharmacies are in-network and covered under your benefits.

Counterforce Health: Your Coverage Advocate

When facing complex prior authorization requirements or insurance denials, Counterforce Health helps patients, clinicians, and specialty pharmacies turn denials into targeted, evidence-backed appeals. Their platform ingests denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned to each payer's specific rules, pulling the right citations and clinical evidence to strengthen your case.

Frequently Asked Questions

Q: How long does Aetna prior authorization take for Alecensa in New Jersey? A: Standard requests take 5-7 business days via electronic submission, or up to 30 days by fax. Expedited requests are decided within 72 hours when medical urgency is documented.

Q: What if Alecensa is non-formulary on my Aetna plan? A: Request a formulary exception with your prior authorization. Include prescriber attestation explaining why Alecensa is medically necessary compared to formulary alternatives.

Q: Can I request an expedited appeal if Aetna denies coverage? A: Yes, if your doctor believes the standard appeal timeline could cause serious harm to your health. Call 1-844-362-0934 to request expedited review.

Q: Does step therapy apply if I've tried other ALK inhibitors outside New Jersey? A: Yes, document all prior ALK inhibitor trials regardless of where treatment occurred. Include clinical notes showing failure or intolerance to support your Alecensa request.

Q: What happens if I move between Aetna plans during treatment? A: New Jersey's continuity of care protections typically provide at least 90 days of continued coverage when changing plans during active cancer treatment.

Q: How do I check my prior authorization status? A: Log into your Aetna member portal or call the member services number on your ID card. Your prescriber can also check status through the CVS Caremark provider portal.

When to Escalate

If you encounter ongoing issues with Aetna's coverage decisions, you can file a complaint with:

For additional support navigating insurance coverage challenges, Counterforce Health specializes in creating targeted appeals that address payer-specific requirements and improve approval rates.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific insurance plan and medical circumstances. Always consult with your healthcare provider and insurance plan for personalized guidance regarding your treatment and coverage options.

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