By Counterforce Health Team in Alecensa (alectinib) —

How to Get Alecensa (alectinib) Covered by Aetna CVS Health in New York: Appeals, Forms & Success Strategies

Answer Box: Fast-Track to Alecensa Coverage

Getting Alecensa (alectinib) covered by Aetna CVS Health in New York requires prior authorization with ALK testing documentation. The fastest path: (1) Ensure your oncologist submits complete ALK-positive test results with the PA request, (2) Include surgical/treatment history if seeking adjuvant coverage, and (3) If denied, file an internal appeal within 180 days. New York residents benefit from expedited external appeals (24-hour decisions for urgent drug denials) through the Department of Financial Services. Start today: Call Aetna at 1-866-785-5714 to verify your plan's PA requirements and obtain the correct forms.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Common Denial Reasons & How to Fix Them
  4. Appeals Playbook for New York Residents
  5. Medical Necessity Letter Template
  6. Costs & Financial Assistance
  7. When to Escalate to State Regulators
  8. Frequently Asked Questions

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Alecensa prescriptions Aetna provider portal or call 1-866-785-5714 Aetna PA Drug List
ALK Testing FDA-approved test showing ALK-positive status Lab report from pathology/molecular diagnostics Aetna Coverage Policy
Formulary Tier Specialty tier (varies by plan) CVS Caremark formulary lookup Caremark.com
Initial Authorization 12 months for metastatic/advanced disease Aetna clinical policy Aetna Coverage Criteria
Appeal Deadline 180 days from denial notice Member handbook or denial letter Aetna Member Services

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and PA Requirements

Who: Patient or clinic staff
Action: Call Aetna at 1-866-785-5714 to confirm your specific plan covers Alecensa and obtain PA forms
Timeline: Same day
Documents needed: Insurance card, member ID

2. Gather Essential Documentation

Who: Healthcare team
Required documents:

  • ALK-positive test results (FISH, IHC, or NGS)
  • Complete pathology report
  • Treatment history (prior therapies, responses, failures)
  • Surgical reports (if seeking adjuvant coverage)
  • Current staging information

3. Submit Prior Authorization

Who: Prescribing oncologist
Method: Fax to CVS Caremark at 1-855-633-7673 or submit via provider portal
Timeline: Allow 30-45 days for standard review
Key: Include comprehensive medical necessity letter (template below)

4. Monitor Decision Status

Who: Patient and clinic
Action: Check status via Caremark.com or call member services
Follow-up: Contact provider if no response within standard timeframe

5. If Denied: Request Peer-to-Peer Review

Who: Prescribing physician
Action: Call 1-866-785-5714 within 72 hours of denial
Prep: Have clinical rationale, guidelines, and patient history ready

6. File Internal Appeal (If Still Denied)

Who: Patient or authorized representative
Deadline: 180 days from denial date
Method: Written appeal with supporting documentation

7. External Appeal (New York Advantage)

Who: Patient
Deadline: 4 months from final adverse determination
Process: File with NY Department of Financial Services
Timeline: 24 hours for expedited drug appeals

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Missing ALK test results Submit complete molecular pathology report Original lab report with methodology and positive result
Insufficient treatment history Provide detailed prior therapy documentation Treatment timeline with outcomes, toxicities, or failures
Step therapy requirement Document contraindications or failures of preferred agents Medical records showing intolerance or inadequate response
"Not medically necessary" Submit comprehensive medical necessity letter Clinical guidelines, FDA labeling, peer-reviewed literature
Adjuvant use questioned Provide surgical and staging documentation Operative reports, pathology, TNM staging
Tip: The most successful appeals include the original ALK testing report—not just a summary—along with specific citations from NCCN guidelines or FDA labeling.

Appeals Playbook for New York Residents

New York offers robust patient protections for insurance appeals, giving you multiple pathways to challenge denials.

Internal Appeals (Required First Step)

  • Deadline: 180 days from denial notice
  • Method: Written request to Aetna with supporting documentation
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Address: Submit via member portal or mail to address on denial letter

External Appeals (New York's Advantage)

New York's external appeal process through the Department of Financial Services is particularly strong for specialty drug denials.

Key Benefits:

  • Independent medical expert review
  • Binding decisions on insurers
  • 24-hour decisions for urgent drug appeals
  • Appeals fee refunded if you win

How to File:

  1. Complete NY External Appeal Application
  2. Include physician attestation for expedited review
  3. Submit to: NY Dept. of Financial Services, 99 Washington Avenue, Box 177, Albany NY 12210
  4. Or fax to: (800) 332-2729

Timeline for Drug Appeals:

  • Standard: 72 hours
  • Expedited: 24 hours (if delay may seriously jeopardize health)
Note: New York's external appeal database shows precedent decisions that can strengthen your case. Search previous rulings at the DFS External Appeals Database.

Medical Necessity Letter Template

Essential Components for Alecensa Appeals

Patient Information Section:

  • Full name, DOB, member ID
  • Diagnosis with ICD-10 codes
  • ALK-positive NSCLC confirmation
  • Current performance status (ECOG/WHO)

Clinical Justification:

[Patient Name] has been diagnosed with ALK-positive non-small cell lung cancer, 
confirmed by [testing method] on [date]. ALK rearrangement testing was performed 
using [FDA-approved test] and shows positive results (copy enclosed).

Based on current NCCN Guidelines (Version X.2024), alectinib is a Category 1, 
preferred first-line treatment for metastatic ALK-positive NSCLC. FDA labeling 
supports this indication, and clinical trials demonstrate superior efficacy 
compared to chemotherapy.

Prior Treatment Documentation:

  • List all previous therapies with dates
  • Document treatment responses or failures
  • Explain contraindications to alternative agents

Monitoring Plan:

  • Laboratory monitoring schedule (LFTs, CPK)
  • Imaging surveillance plan
  • Adverse event management strategy

Costs & Financial Assistance

Alecensa's wholesale acquisition cost is approximately $19,466 per 240-count bottle, making financial assistance crucial for many patients.

Available Support Programs:

Genentech Patient Foundation

  • Provides free medication for eligible uninsured patients
  • Income limits apply (typically 400% of federal poverty level)
  • Apply at Genentech-Access.com

Copay Assistance

  • Commercial insurance patients may qualify for copay reduction
  • Can significantly reduce out-of-pocket costs
  • Not available for government insurance (Medicare, Medicaid)

New York State Programs

  • Essential Plan for lower-income residents
  • Medicaid expansion covers many specialty medications
  • Contact NY State of Health marketplace for eligibility

When to Escalate to State Regulators

If your appeals are unsuccessful or you experience unfair treatment, New York provides additional oversight mechanisms.

File a Complaint With:

New York Department of Financial Services

  • Regulates insurance companies in New York
  • Investigates complaints about claim denials
  • Phone: 1-800-342-3736
  • Online complaint form

Community Health Advocates

  • Free assistance with insurance appeals
  • Helpline: 888-614-5400
  • Specializes in helping New Yorkers navigate coverage denials

When to Contact Regulators:

  • Appeals process exceeded legal timeframes
  • Insurer failed to follow proper procedures
  • Pattern of inappropriate denials
  • Lack of response to legitimate requests

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take for Alecensa in New York? Standard PA decisions take 30-45 days. Expedited reviews for urgent cases are completed within 72 hours. Track your request via the Caremark member portal or by calling 1-866-785-5714.

What if Alecensa is non-formulary on my Aetna plan? Request a formulary exception with clinical documentation showing medical necessity. Include evidence that formulary alternatives are inappropriate due to contraindications, previous failures, or drug interactions.

Can I request an expedited appeal if my condition is urgent? Yes. If delay in treatment may seriously jeopardize your health, request expedited review. Your physician must complete an attestation confirming the urgent nature of your condition.

Does step therapy apply if I've tried other ALK inhibitors outside New York? Treatment history from any location counts toward step therapy requirements. Ensure your appeal includes complete documentation of prior therapies, regardless of where treatment occurred.

What happens if I lose my external appeal in New York? External appeal decisions are binding, but you may have other options including filing complaints with state regulators, seeking alternative treatments, or exploring patient assistance programs.

How much will Alecensa cost with Aetna coverage? Costs depend on your specific plan design. Specialty tier copays typically range from $100-500 per month, though some plans use coinsurance instead. Check your Summary of Benefits or call member services for exact amounts.

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical documentation to create targeted, evidence-backed appeals. The platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and craft compelling medical necessity arguments that align with each payer's specific criteria.

If you're facing a complex Alecensa denial or need help crafting a comprehensive appeal, Counterforce Health's platform can analyze your specific situation and generate targeted appeal documentation that addresses your plan's exact requirements and denial reasons.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan, and policies change frequently. Always verify current requirements with your insurance provider and consult your healthcare team for medical decisions. For personalized assistance with insurance appeals in New York, contact Community Health Advocates at 888-614-5400.

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