By Counterforce Health Team in Alprolix (coagulation factor IX, rFIXFc; eftrenonacog alfa) —

How to Get Alprolix (Eftrenonacog Alfa) Covered by Aetna CVS Health in Washington: Complete Coding, Prior Authorization & Appeals Guide

Answer Box: Getting Alprolix Approved by Aetna CVS Health in Washington

Alprolix (eftrenonacog alfa) requires prior authorization from Aetna CVS Health with proper coding and documentation. Use ICD-10 code D67 for hemophilia B, HCPCS code J7202 for billing, and ensure your hematologist submits complete clinical justification. If denied, Washington residents have strong appeal rights through the state's binding Independent Review Organization (IRO) process. Start today by gathering your bleeding history, inhibitor test results, and having your specialist submit a comprehensive medical necessity letter.

Table of Contents

  1. Coding Basics for Alprolix Coverage
  2. ICD-10 Requirements and Documentation
  3. HCPCS J-Codes and NDC Numbers
  4. Building a Clean Prior Authorization Request
  5. Common Coding Pitfalls to Avoid
  6. Verification with Aetna CVS Health Resources
  7. Pre-Submission Audit Checklist
  8. Appeals Process in Washington
  9. FAQ

Coding Basics for Alprolix Coverage

Alprolix (eftrenonacog alfa) is an extended half-life factor IX concentrate that requires careful coding to ensure proper coverage determination by Aetna CVS Health. The medication follows both medical and pharmacy benefit pathways depending on your plan structure.

Medical vs. Pharmacy Benefit Paths

Medical Benefit (Buy-and-Bill):

  • Used when administered in clinic/hospital settings
  • Requires HCPCS J-code J7202 for billing
  • Must include site of care and administration details
  • Typically covers doses administered during bleeding episodes or perioperative management

Pharmacy Benefit (Home Infusion):

  • For patient self-administration or home health
  • Processed through CVS Specialty pharmacy
  • Requires NDC codes and quantity calculations
  • Used primarily for prophylaxis regimens
Note: Most Aetna plans route Alprolix through the specialty pharmacy benefit, requiring prior authorization through CVS Caremark's system.

ICD-10 Requirements and Documentation

Primary Diagnosis Code

ICD-10 Code D67 is the correct code for hereditary factor IX deficiency (hemophilia B). This code must appear on all claims and prior authorization requests for Alprolix coverage.

Required Documentation for D67

Your medical records must explicitly document:

  • Confirmed hereditary factor IX deficiency with laboratory evidence
  • Factor IX activity levels (typically <40% for diagnosis, <1% for severe disease)
  • Family history demonstrating inherited pattern when available
  • Clinical manifestations including bleeding episodes and response to treatment
  • Inhibitor status via Bethesda assay results
Tip: Ensure your hematologist's notes specifically state "hereditary factor IX deficiency" rather than just "hemophilia B" to support the D67 coding.

Documentation Words That Support Coding

Include these specific terms in medical records:

  • "Hereditary factor IX deficiency"
  • "Christmas disease"
  • "Congenital bleeding disorder"
  • "Factor IX activity [specific percentage]"
  • "Negative inhibitor screen"
  • "Prophylactic factor replacement therapy"

HCPCS J-Codes and NDC Numbers

HCPCS Code for Alprolix

J7202 - "Injection, coagulation factor IX (recombinant), Fc fusion protein (Alprolix), per IU"

This code is specific to eftrenonacog alfa and should be used for all Alprolix billing.

NDC Numbers by Vial Strength

Strength NDC Code Typical Use
250 IU 71104-925-01 Pediatric dosing
500 IU 71104-926-01 Low-dose prophylaxis
1000 IU 71104-922-01 Standard adult dose
2000 IU 71104-976-01 High-dose prophylaxis
3000 IU 71104-977-01 On-demand treatment
Important: Always verify NDC codes on the actual vial label, as manufacturers may update packaging codes.

Billing Units Calculation

1 billing unit = 1 International Unit (IU) of factor IX activity.

Example Calculation:

  • Patient weight: 70 kg
  • Prophylaxis dose: 50 IU/kg weekly
  • Weekly dose: 70 kg × 50 IU/kg = 3,500 IU
  • Billing units: 3,500 units

For partial vials, round up to the next full vial and bill for the total IU contained in all vials used.

Building a Clean Prior Authorization Request

Essential Components

A complete prior authorization for Alprolix must include:

Clinical Information:

  • ICD-10 code D67 with supporting lab values
  • Current factor IX activity level
  • Inhibitor test results (Bethesda assay within 30 days)
  • Bleeding history and frequency
  • Prior factor concentrate trials and outcomes

Prescriber Details:

  • Board-certified hematologist required
  • Provider NPI and taxonomy code
  • Specialty clinic affiliation

Dosing Justification:

  • Weight-based calculations showing medical necessity
  • Prophylaxis schedule (typically 50 IU/kg weekly)
  • Pharmacokinetic considerations for extended half-life benefit

Supporting Documentation:

  • Recent CBC and comprehensive metabolic panel
  • Hepatitis B/C and HIV screening
  • Liver function tests
  • Treatment goals and monitoring plan

Example Clean Request Format

Patient: [Name], DOB [Date]
Diagnosis: Hereditary factor IX deficiency (ICD-10: D67)
Factor IX activity: <1% (severe hemophilia B)
Inhibitor status: Negative (Bethesda <0.6 BU, [date])

Requested therapy: Alprolix (eftrenonacog alfa)
Dose: 3,500 IU (50 IU/kg) every 7 days
NDC: 71104-977-01 (3000 IU) + 71104-926-01 (500 IU)
J-code: J7202

Clinical rationale: Extended half-life factor IX for prophylaxis
to prevent spontaneous bleeding episodes in severe hemophilia B.
Patient requires weekly dosing due to [specific clinical factors].

Common Coding Pitfalls to Avoid

Unit Conversion Errors

Mistake: Billing 35 units for a 3,500 IU dose Correction: Bill 3,500 units (1 IU = 1 billing unit)

Mismatched Codes

Mistake: Using J7200 (generic factor IX) instead of J7202 Correction: Always use J7202 specifically for Alprolix

Missing Start Dates

Mistake: Submitting PA without clear therapy start date Correction: Include specific start date and duration of therapy

Incomplete NDC Reporting

Mistake: Reporting only the J-code without NDC Correction: Include both J7202 and specific NDC codes for each vial strength used

Verification with Aetna CVS Health Resources

Check Formulary Status

  1. Log into Aetna member portal to verify current formulary placement
  2. Review your specific plan's drug list - Alprolix may be non-preferred or excluded on some formularies
  3. Check for quantity limits that may affect your prescribed dosing schedule

Prior Authorization Requirements

Confirm current PA requirements through:

  • Aetna provider portal (verify current link)
  • CVS Caremark specialty pharmacy at 1-800-237-2767
  • Your plan's Summary of Benefits and Coverage (SBC)

Coverage Policies

Review Aetna's current hemophilia factor policies for:

  • Step therapy requirements
  • Preferred factor IX products
  • Site of care restrictions
  • Age limitations

Pre-Submission Audit Checklist

Before submitting your Alprolix prior authorization, verify:

Coding Accuracy:

  • ICD-10 D67 documented with supporting labs
  • HCPCS J7202 specified for Alprolix
  • Correct NDC codes for prescribed vial strengths
  • Accurate unit calculations (IU = billing units)

Clinical Documentation:

  • Hematologist prescriber with valid NPI
  • Factor IX activity <40% documented
  • Negative inhibitor screen within 30 days
  • Bleeding history and prior treatments detailed
  • Weight-based dosing calculations shown

Administrative Details:

  • Patient demographics match insurance card
  • Prior authorization form completely filled
  • All required signatures present
  • Submission method confirmed (portal vs. fax)

Appeals Process in Washington

Washington State provides robust protections for patients facing Alprolix denials through its Independent Review Organization (IRO) process.

Internal Appeals with Aetna

Timeline: 180 days from denial to file Process: Submit through Aetna member portal or by mail Decision: Standard appeals decided within 30-45 days; expedited within 72 hours

External Review (IRO)

If Aetna upholds the denial, Washington residents can request binding external review:

Who Decides: Independent medical specialists (hematologists for hemophilia cases) Timeline: 15 business days for standard review; 72 hours for urgent cases Cost: Free to patients Authority: IRO decisions are legally binding on Aetna

How to Request IRO Review

  1. Contact Washington Office of Insurance Commissioner at 1-800-562-6900
  2. File within 21 days of Aetna's final internal denial
  3. Submit all medical records and supporting documentation
  4. Include specialist letter explaining medical necessity
Key Advantage: Washington's IRO reviewers must be actively practicing specialists in the relevant field, ensuring expert evaluation of hemophilia treatment needs.

When to Escalate

Contact the Washington Office of Insurance Commissioner if:

  • Aetna fails to respond to urgent requests within 24 hours
  • Internal appeal process exceeds stated timeframes
  • You believe the denial was based on incorrect information

Contact Information:

  • Phone: 1-800-562-6900
  • Website: insurance.wa.gov
  • Appeal guidance: Available online with template letters

FAQ

Q: How long does Aetna CVS Health prior authorization take for Alprolix in Washington? A: Standard PA decisions are typically rendered within 15 business days. Expedited reviews for urgent medical situations are completed within 72 hours.

Q: What if Alprolix is excluded from my Aetna formulary? A: You can request a formulary exception by demonstrating medical necessity and providing evidence that preferred alternatives are inappropriate for your specific case.

Q: Can I request an expedited appeal if I'm actively bleeding? A: Yes. Washington law requires expedited review within 72 hours for situations where your health could be seriously jeopardized by delays.

Q: Does step therapy apply if I've previously failed other factor IX products? A: Prior failures can exempt you from step therapy requirements. Ensure your hematologist documents specific reasons why alternative treatments were inadequate.

Q: What happens if the IRO overturns Aetna's denial? A: The decision is legally binding. Aetna must immediately authorize coverage and cannot appeal the IRO's determination.

Q: Are there cost assistance programs for Alprolix? A: Yes. Sobi (the manufacturer) offers patient assistance programs. Additionally, check with the National Hemophilia Foundation and state programs for additional support options.

About Counterforce Health

Counterforce Health specializes in helping patients, clinicians, and specialty pharmacies overcome insurance denials for prescription medications. Our platform analyzes denial letters, plan policies, and clinical documentation to create targeted, evidence-backed appeals that align with each payer's specific requirements. For complex cases like hemophilia factor concentrates, we help ensure that all necessary clinical evidence, coding requirements, and procedural steps are properly addressed to maximize approval chances.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for specific guidance regarding your coverage and treatment options. Insurance policies and requirements may vary by plan and can change over time.

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