By Counterforce Health Team in Elelyso (taliglucerase alfa) —

How to Get Elelyso (Taliglucerase Alfa) Covered by Aetna CVS Health in Illinois: Complete Guide with Forms, Timelines, and Appeal Scripts

Answer Box: Quick Path to Elelyso Coverage

Elelyso (taliglucerase alfa) requires prior authorization from Aetna CVS Health in Illinois. Submit your PA request at least two weeks in advance via the Availity provider portal with complete Gaucher disease Type 1 documentation. Good news: Illinois banned step therapy for specialty medications on formulary as of January 1, 2025, so no step-through requirements apply to fully insured plans. If denied, you have 180 days for internal appeals and 4 months for external review through the Illinois Department of Insurance. First step today: Confirm your plan type (fully insured vs. self-insured) and gather diagnostic records, prior therapy history, and prescriber attestation.

Table of Contents

Why Illinois State Rules Matter

Illinois insurance law provides stronger protections for specialty medication access than many states, especially for enzyme replacement therapies like Elelyso. These state rules interact with Aetna CVS Health's national policies to create specific advantages for Illinois patients.

Key Illinois advantages:

  • No step therapy requirements for specialty medications on formulary (effective January 1, 2025)
  • 4-month window for external reviews (longer than some states)
  • Expedited external review decisions within 72 hours for urgent cases
  • Continuity of care protections during plan transitions
Important: These protections apply to fully insured commercial plans. Self-insured (ERISA) employer plans may still have step therapy requirements and different appeal processes.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before dispensing Aetna 2025 Precertification List Aetna
Formulary Status Covered with PA CVS Caremark formulary CVS Caremark
Step Therapy None for IL fully insured Illinois statute 215 ILCS 5/155.37 Illinois DOI
Age Requirement ≥4 years FDA labeling FDA
Diagnosis Confirmed Type 1 Gaucher disease Aetna clinical criteria Aetna
Prescriber Specialist preferred Aetna PA criteria Aetna
Appeals Deadline 180 days internal, 4 months external Illinois Health Carrier External Review Act Illinois DOI

Step-by-Step: Fastest Path to Approval

1. Verify Plan Type and Coverage (Patient/Clinic)

  • Check if your Aetna plan is fully insured (subject to Illinois law) or self-insured (ERISA)
  • Confirm Elelyso is on your specific formulary
  • Timeline: Same day
  • Source: Aetna member services or member ID card

2. Gather Required Documentation (Clinic)

  • Confirmed Type 1 Gaucher disease diagnosis (enzyme levels, genetic testing)
  • Prior therapy history and failures/intolerances
  • Current clinical status and treatment goals
  • Prescriber attestation of medical necessity
  • Timeline: 1-3 days
  • Source: Patient medical records

3. Submit Prior Authorization (Prescriber)

4. Follow Up on Decision (Patient/Clinic)

  • Standard decisions: 30-45 days
  • Expedited decisions: 72 hours or less
  • Request written denial with specific reasons if denied
  • Timeline: Per Aetna policy
  • Source: Aetna determination letter

Illinois Step Therapy Protections

Major win for Illinois patients: As of January 1, 2025, Illinois law prohibits step therapy requirements for prescription drugs on the plan formulary, including specialty medications like Elelyso.

What this means:

  • No step-through required for fully insured Aetna plans
  • No need to try cheaper alternatives first if Elelyso is medically appropriate
  • Simplified approval process focused on medical necessity, not cost-based protocols
Note: Self-insured employer plans are exempt from this Illinois law and may still require step therapy. Check with your HR department if unsure about your plan type.

Actionable step: When submitting your PA, reference Illinois statute 215 ILCS 5/155.37 if Aetna requests step therapy for a fully insured plan.

Continuity of Care During Transitions

Illinois provides strong continuity protections if you're already on Elelyso and face coverage changes:

Mid-year formulary protection: Under Illinois Public Act 100-1052, insurers cannot remove medications from formulary or shift cost-sharing tiers mid-year for chronic conditions like Gaucher disease.

Transition coverage: If switching plans or your provider leaves Aetna's network:

  • 90 days of continued coverage at in-network rates
  • Grace periods for missed premium payments (typically 30 days)
  • Medicaid reinstatement within 90 days if paperwork issues occur

What to do: If you receive notice of formulary or network changes, immediately contact Aetna member services and request continuity of care protection. Have your prescriber submit supporting documentation within the notice period.

Appeals Playbook for Aetna CVS Health

Internal Appeals Process

Level 1: Standard Internal Appeal

  • Deadline: 180 days from denial date
  • Timeline: 15 business days for pre-service requests
  • How to file: Aetna member portal or written request
  • What to include: Denial letter, additional medical records, prescriber letter

Level 2: Expedited Internal Appeal

  • When to use: Urgent medical need or delay would harm health
  • Timeline: 24-72 hours
  • Certification: Prescriber must attest to urgency

External Review (Illinois Department of Insurance)

When eligible: After internal appeal denial, or immediately for urgent cases

  • Deadline: 4 months from final internal denial
  • Timeline: 5 business days after IRO receives records
  • Cost: Free to patients
  • How to file: Illinois DOI external review form

Expedited external review:

  • Timeline: 72 hours
  • When available: Serious health jeopardy or experimental/investigational treatments

Scripts and Templates

Patient Phone Script for Aetna Member Services

"Hi, I'm calling about a prior authorization denial for Elelyso, taliglucerase alfa, for my Type 1 Gaucher disease. My member ID is [ID number]. I'd like to understand the specific denial reason and start an internal appeal. Can you also confirm if my plan is fully insured and subject to Illinois law, which prohibits step therapy for specialty medications? I'll need the appeal form and deadline information."

Prescriber Peer-to-Peer Script

"I'm requesting a peer-to-peer review for Elelyso approval for my patient with confirmed Type 1 Gaucher disease. The patient has [specific clinical details]. Given Illinois law prohibiting step therapy for specialty medications on formulary, and the FDA approval for this exact indication, I believe this denial should be overturned. Can we schedule a clinical review?"

When to Escalate to State Regulators

Contact the Illinois Department of Insurance if:

  • Aetna violates Illinois step therapy prohibitions
  • Appeal deadlines aren't met
  • External review process is delayed
  • You need help navigating the system

Illinois Department of Insurance Office of Consumer Health Insurance (OCHI)

  • Phone: 877-527-9431
  • Website: idoi.illinois.gov
  • What they do: Free assistance with appeals, external reviews, and insurance complaints

Illinois Attorney General Health Care Helpline

  • Phone: 1-877-305-5145
  • Services: Informal intervention with insurers, complex appeal assistance

Counterforce Health specializes in turning insurance denials into evidence-backed appeals. Their platform analyzes denial letters and plan policies to create targeted rebuttals that align with payer-specific requirements, potentially saving weeks of back-and-forth with insurers like Aetna CVS Health.

FAQ

How long does Aetna CVS Health prior authorization take in Illinois? Standard PA decisions typically take 30-45 days. Expedited requests for urgent medical needs are processed within 72 hours. Submit at least two weeks before you need the medication.

What if Elelyso is non-formulary on my Aetna plan? You can request a formulary exception with documentation of medical necessity. Illinois continuity protections may apply if you were previously covered. Consider appealing based on lack of therapeutic alternatives.

Can I request an expedited appeal in Illinois? Yes, both Aetna and Illinois law allow expedited appeals when delay would seriously jeopardize health. Your prescriber must certify the urgency in writing.

Does Illinois step therapy protection apply to all Aetna plans? No, only fully insured commercial plans. Self-insured employer plans governed by ERISA are exempt from Illinois step therapy prohibitions.

What happens if I miss the appeal deadline? Illinois provides some flexibility for "good cause" delays, but act quickly. Contact the Illinois Department of Insurance for assistance if you've missed deadlines due to circumstances beyond your control.

How much does Elelyso cost without insurance? The wholesale acquisition cost is approximately $839-$899 per 200-unit vial, with typical monthly costs ranging from $3,000-$7,000 depending on dosing. Pfizer offers patient assistance programs for eligible patients.

This guide provides educational information and should not replace medical advice. Always consult your healthcare provider for medical decisions. For official Illinois insurance regulations and current forms, visit the Illinois Department of Insurance. Counterforce Health provides specialized support for complex prior authorization and appeal processes.

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