By Counterforce Health Team in Darzalex / Darzalex Faspro (daratumumab) —

How to Get Darzalex (Daratumumab) Covered by Aetna CVS Health in New Jersey: Complete PA Forms, Appeals Guide & Contact Directory

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

Aetna CVS Health requires prior authorization for Darzalex (daratumumab) in New Jersey, submitted via Availity portal or CVS Caremark at 1-800-294-5979. Coverage typically requires documentation of FDA-approved multiple myeloma indications, prior therapy failures, and prescriber attestation. If denied, you can appeal through Aetna's internal process (60 days) then file an external review with New Jersey's IHCAP program through Maximus (120 days from final denial). Start today by verifying your plan's formulary status and downloading the PA form from Aetna's provider portal.

Table of Contents

Verify Your Plan & Find the Right Forms

Before starting your prior authorization request, confirm your specific Aetna plan type and Darzalex's formulary status:

Check Your Plan Type:

  • Commercial/Employer Plans: Use standard Aetna PA process
  • Medicare Part D: Requires Medicare-specific forms and timelines
  • Medicaid/Better Health: May have different requirements

Verify Formulary Status: Access the Aetna drug formulary tool or call member services at 1-855-232-3596 to check if Darzalex requires:

  • Prior authorization
  • Step therapy (trying other drugs first)
  • Quantity limits
  • Preferred specialty pharmacy
Tip: If Darzalex isn't on your formulary at all, you'll need to file a formulary exception request along with your PA.

Coverage at a Glance

Requirement What It Means Where to Find It Timeline
Prior Authorization Must get approval before dispensing Aetna Provider Portal Standard: ≤72 hours
Step Therapy Try preferred drugs first Plan formulary or call member services Override possible with documentation
Specialty Pharmacy Must use designated network pharmacy CVS Specialty: 1-800-237-2767 Setup before PA approval
Medical Necessity Clinical documentation required Prescriber letter + chart notes Submit with initial PA

Prior Authorization Forms & Requirements

Fastest option: Submit via Availity portal for automated processing. Many Darzalex requests receive decisions within 6 seconds through electronic submission.

Paper Forms

Non-Medicare Plans:

Medicare Part D Plans:

Required Documentation

Clinical Information Needed:

  • Patient age (≥18 years for most indications)
  • Multiple myeloma diagnosis with ICD-10 code (e.g., C90.00)
  • Prior therapy history and failures/intolerance
  • Planned dosing regimen (IV vs. subcutaneous)
  • Prescriber specialty and NPI number

Medical Necessity Criteria (Based on FDA Indications):

  • Newly diagnosed MM (transplant-ineligible): + lenalidomide/dexamethasone
  • Relapsed/refractory MM: Monotherapy after ≥3 prior lines OR combination therapy after ≥1 prior line
  • High-risk smoldering MM: Monotherapy (newer indication)

Submission Portals & Electronic Options

Primary Electronic Portals

Availity (Recommended)

  • URL: availity.com
  • Benefits: Real-time decisions, integrated with EHR systems
  • Account Required: Yes (free provider registration)
  • Upload Capability: Chart notes, labs, prior therapy documentation

CVS Caremark Provider Portal

  • Access through caremark.com
  • Hours: Monday-Friday, 8 AM-6 PM CST
  • Status Tracking: Real-time PA status updates

Alternative Electronic Systems

  • CoverMyMeds: Integrated with many EHR systems
  • Surescripts: Available through practice management software
  • Arrive Health: Direct portal access

Fax Numbers & Mailing Addresses

CVS Caremark Prior Authorization

Non-Medicare Plans:

  • Fax: 1-888-836-0730
  • Phone: 1-800-294-5979
  • Hours: Monday-Friday, 8 AM-6 PM CST

Medicare Part D:

  • Phone: 1-855-344-0930
  • Fax: (verify current number with member services)

Cover Sheet Tips

Include on every fax:

  • Patient name and member ID
  • Drug name: "Darzalex (daratumumab)" or "Darzalex Faspro"
  • Prescriber name and NPI
  • "URGENT: Prior Authorization Request" (if applicable)
  • Total page count

Specialty Pharmacy Setup

Aetna requires Darzalex to be dispensed through designated specialty pharmacies. Set this up before your PA is approved to avoid delays.

Aetna Preferred Specialty Pharmacies in New Jersey

CVS Specialty (Primary Network)

  • Phone: 1-800-237-2767
  • Coverage: All 50 states
  • Services: Home delivery, clinical support

Regional Options:

  • Bergen Pharmacy (Newark, NJ): 1-973-273-1100
  • Biomatrix Specialty Pharmacy: 1-800-510-0765

Transfer Process

  1. Call your current pharmacy to request prescription transfer
  2. Provide new specialty pharmacy contact information
  3. Confirm insurance coverage verification
  4. Schedule delivery/pickup once PA is approved

Member & Provider Support Lines

Aetna Better Health of New Jersey

Member Services: 1-855-232-3596 (TTY: 711)

  • Hours: 24/7
  • Services: Plan benefits, PA status, appeals assistance

Provider Services: 1-855-232-3596

  • Hours: 24/7
  • Services: Contracting, credentialing, PA support

Case Management & Clinical Support

For complex cases requiring case management:

  • Call member services number on your ID card
  • Request transfer to case management
  • Mention "oncology specialty medication" for appropriate routing

J&J withMe Program Support

  • Website: jnjwithme.com
  • Services: PA templates, appeal letters, insurance navigation

New Jersey Appeals & External Review

Internal Appeals Process

Timeline: 60 days from denial notice to file Methods:

  • Online: Availity portal (providers)
  • Phone: 1-855-232-3596
  • Mail: Include denial letter and additional documentation

Standard Review: ≤7 days Expedited Review: ≤72 hours (if delay could harm health)

External Review Through IHCAP

If Aetna denies your internal appeal, New Jersey's Independent Health Care Appeals Program (IHCAP) provides binding external review through Maximus.

Eligibility: Must complete internal appeals first Timeline: 120 days from final internal denial to file Cost: Free to patients

Contact Maximus:

Review Timeline:

  • Standard: Decision within 45 days
  • Expedited: Decision within 48 hours

Required Documents:

  • Initial Aetna denial letter
  • Internal appeal decision(s)
  • Medical records supporting medical necessity
  • Completed consent forms
Important: IHCAP decisions are binding on Aetna for New Jersey-regulated plans.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Documentation Needed
"Not medically necessary" Submit medical necessity letter Chart notes, lab results, treatment history
"Experimental/investigational" Provide FDA approval evidence FDA label, NCCN guidelines, peer-reviewed studies
Step therapy not completed Request step therapy override Prior therapy failures/intolerance documentation
Non-formulary drug File formulary exception Prescriber letter explaining why formulary alternatives are inappropriate
Quantity/dosing limits exceeded Justify dosing rationale Weight-based calculations, FDA dosing guidelines
Wrong site of care Clarify administration setting Infusion center credentials, safety protocols

Clinician Corner: Medical Necessity Letter Checklist

Essential Elements:

  • Patient's multiple myeloma diagnosis and staging
  • Prior treatments tried and reasons for discontinuation
  • Clinical rationale for Darzalex specifically
  • Expected treatment goals and monitoring plan
  • Guideline support (NCCN, ASH, IMWG)

Key Clinical Citations:

FAQ: Aetna Darzalex Coverage in New Jersey

How long does Aetna PA take for Darzalex in New Jersey? Standard prior authorization decisions are made within 72 hours. Electronic submissions through Availity may receive automated approval in seconds for straightforward cases.

What if Darzalex isn't on my Aetna formulary? File a formulary exception request along with your PA. Include prescriber documentation explaining why formulary alternatives are medically inappropriate.

Can I request expedited review if I need Darzalex urgently? Yes. If delay would jeopardize your health, request expedited review (≤24 hours for coverage decisions, ≤72 hours for appeals).

Does step therapy apply if I tried other drugs outside New Jersey? Yes, but you must provide documentation of prior therapies and outcomes. Out-of-state medical records are acceptable with proper documentation.

What happens if Aetna denies my appeal? You can file an external review with New Jersey's IHCAP program through Maximus within 120 days. Their decision is binding on Aetna.

Are there patient assistance programs for Darzalex? Yes, J&J offers copay assistance and patient support programs. Visit jnjwithme.com for eligibility requirements and applications.

When to Escalate: State Resources

If you encounter problems with Aetna's process or need additional help:

New Jersey Department of Banking and Insurance (DOBI)

  • Consumer Hotline: 1-800-446-7467
  • IHCAP Specific: 1-888-393-1062
  • Website: nj.gov/dobi

Services Available:

  • Plan compliance complaints
  • Appeal process guidance
  • Consumer protection assistance

How Counterforce Health Can Help

Counterforce Health specializes in turning insurance denials into successful appeals for specialty medications like Darzalex. Our platform analyzes your specific denial letter and Aetna's policy requirements, then drafts targeted, evidence-backed appeals that address each denial reason point-by-point. We help patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeal processes, significantly improving approval rates for medically necessary treatments.

For patients facing Darzalex denials from Aetna in New Jersey, Counterforce Health provides the clinical documentation, guideline citations, and procedural expertise needed to build compelling appeals that meet both Aetna's specific criteria and New Jersey's regulatory requirements.

Update Cadence: Staying Current

Check for updates every 6 months:

  • Aetna formulary changes (typically January 1)
  • New FDA indications for Darzalex
  • New Jersey IHCAP process updates
  • CVS Specialty pharmacy network changes

Monitor quarterly:

  • Prior authorization form updates
  • Contact number changes
  • Electronic portal enhancements

Sources & Further Reading

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 insurance plan and consult with your healthcare provider regarding treatment decisions. For personalized assistance with insurance appeals and prior authorizations, consider consulting with healthcare coverage specialists.

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