By Counterforce Health Team in Evkeeza (evinacumab-dgnb) —

How to Get Evkeeza (Evinacumab) Approved by Aetna CVS Health in Illinois: Complete Prior Authorization Guide with Appeals Process

Answer Box: Getting Evkeeza Covered by Aetna CVS Health in Illinois

Evkeeza (evinacumab) requires prior authorization from Aetna CVS Health for homozygous familial hypercholesterolemia (HoFH). The fastest path to approval: (1) Confirm HoFH diagnosis with genetic testing or clinical criteria, (2) Document failure of maximum-tolerated statin, ezetimibe, and PCSK9 inhibitor, (3) Submit Aetna's Evkeeza precertification form with complete clinical records via fax to 1-888-267-3277. Start today: Gather your genetic test results and recent LDL-C levels—these are required for all approvals. Illinois residents have strong appeal rights through the Illinois Department of Insurance if initially denied.

Table of Contents

What This Guide Covers

This guide helps Illinois patients and their healthcare providers navigate Aetna CVS Health's prior authorization process for Evkeeza (evinacumab-dgnb), a specialized treatment for homozygous familial hypercholesterolemia (HoFH). We'll walk through the exact forms, documentation requirements, timelines, and appeal processes specific to Illinois regulations.

Who this helps:

  • Patients diagnosed with HoFH who need Evkeeza
  • Healthcare providers submitting prior authorizations
  • Caregivers advocating for coverage decisions
  • Anyone facing an Aetna denial for this medication
Note: This is not medical advice. Always work with your healthcare provider to determine the most appropriate treatment plan.

Before You Start: Verify Your Coverage

Check Your Plan Details

Call Aetna member services at the number on your insurance card to confirm:

  • Your plan includes specialty pharmacy benefits
  • Evkeeza is covered under your specific formulary
  • Whether you need to use CVS Specialty Pharmacy (most Aetna plans require this)
  • Your current deductible and specialty tier copay

Confirm In-Network Status

Ensure your prescribing physician is in-network with your Aetna plan. Out-of-network providers may face additional hurdles or require different forms.

Medical vs. Pharmacy Benefit

Evkeeza is typically covered under the medical benefit (not pharmacy) since it's an IV infusion administered in clinical settings. This affects your copay structure and prior authorization pathway.

Gather What You Need

Essential Documentation Checklist

Clinical Documentation:

  • ✅ HoFH diagnosis confirmation via genetic testing (LDLR, APOB, PCSK9, or LDLRAP1 variants) OR clinical criteria (untreated LDL-C >400 mg/dL plus family history/xanthomas)
  • ✅ Recent LDL-C levels (within 3 months)
  • ✅ Prior therapy documentation showing failure, intolerance, or contraindication to:
    • Maximally tolerated statin
    • Ezetimibe
    • PCSK9 inhibitor (evolocumab or alirocumab)
  • ✅ Current medications list and dosages
  • ✅ ICD-10 code: E78.01 (Familial hypercholesterolemia)

Administrative Items:

  • ✅ Patient insurance card and member ID
  • ✅ Prescribing physician NPI and contact information
  • ✅ Preferred infusion site details

Submit Your Prior Authorization Request

Step-by-Step Submission Process

1. Complete the Precertification Form

  • Fill out every field completely and legibly
  • Attach all supporting clinical documentation
  • Include dosing details: 15 mg/kg IV every 4 weeks
  • Specify planned site of care (outpatient infusion center, hospital outpatient, etc.)

2. Choose Your Submission Method

Fax (Recommended): 1-888-267-3277

  • Most reliable method with confirmation receipt
  • Include cover sheet with patient name and member ID

Phone for Urgent Cases: 1-866-752-7021

  • Use only for expedited/urgent requests
  • Follow up with faxed documentation

Online: Aetna provider portal

  • Available for in-network providers
  • Allows electronic tracking

3. Create a Complete Request Packet

Your submission should include:

  • Completed precertification form
  • Genetic test results or clinical HoFH criteria documentation
  • Laboratory reports (lipid panels)
  • Prior therapy trial records
  • Physician notes supporting medical necessity
  • Any relevant specialist consultations
Tip: Number your pages and include a cover sheet listing all attached documents. This prevents processing delays if pages are separated.

Follow-Up and Tracking

When to Follow Up

  • Day 7: Call to confirm receipt of your submission
  • Day 14: Check on review status
  • Day 21: Request status update if no decision received

What to Ask During Follow-Up Calls

Sample script for clinic staff: "I'm calling to check the status of a prior authorization for Evkeeza for [patient name], member ID [number]. The request was submitted on [date] via fax to 1-888-267-3277. Can you confirm it was received and provide the reference number and expected decision date?"

Document Everything

Keep records of:

  • Submission dates and methods
  • Reference numbers
  • Names of representatives you speak with
  • Any additional information requests

Typical Timelines in Illinois

Request Type Aetna Timeline Illinois Regulation
Standard PA 30-45 business days Must comply with state requirements
Expedited/Urgent 72 hours 24-72 hours for urgent medical needs
Internal Appeal 15 business days Must meet state deadlines
External Review 45 days 5 business days once IRO receives materials

Illinois-specific note: The state requires faster turnaround times than many other states, particularly for internal appeals (15 business days) and external reviews.

If You're Asked for More Information

Common Information Requests

Medical Necessity Questions:

  • Additional lab values or trends over time
  • More detailed prior therapy trial documentation
  • Specialist consultation notes
  • Family history details

Response Strategy:

  • Submit requested information within 10 business days
  • Include a cover letter summarizing why the additional information supports approval
  • Reference specific sections of Aetna's clinical policy that your documentation satisfies

Strengthening Your Case

Include supporting literature when appropriate:

  • FDA prescribing information for Evkeeza
  • Clinical guidelines from lipid specialty societies
  • Peer-reviewed studies demonstrating efficacy in HoFH

If Your Request Is Denied

Understanding Common Denial Reasons

Denial Reason How to Address
"Not medically necessary" Submit detailed medical necessity letter with clinical rationale
"Step therapy not completed" Document prior failures or contraindications to required therapies
"Non-formulary drug" Request formulary exception with supporting evidence
"Insufficient documentation" Provide missing clinical records or lab results

Peer-to-Peer Review

Request immediately after denial:

  • Available for medical necessity denials
  • Allows your physician to speak directly with Aetna's medical director
  • No cost and can resolve issues quickly
  • Contact: 1-866-752-7021

Internal Appeal Process

Timeline: Must file within 60 calendar days of denial notice in Illinois

How to File:

  • Fax: 844-951-2143 (Aetna Better Health Illinois)
  • Mail: PO Box 81040, 5801 Postal Road, Cleveland, OH 44181
  • Email: [email protected]

What to Include:

  • Written appeal letter stating why the denial was incorrect
  • All original documentation plus any new supporting evidence
  • Medical necessity letter from prescribing physician
  • References to Aetna's own coverage policies

Illinois External Review Rights

If your internal appeal is denied, Illinois law guarantees your right to an independent external review by a physician specialist. You have 30 days from the final denial to request this review through the Illinois Department of Insurance.

Contact Illinois Department of Insurance:

The external review decision is binding on Aetna and typically completed within 30 days.

Renewal and Re-Authorization

When to Start Renewal Process

Begin renewal 60 days before your current authorization expires to avoid treatment interruption.

Required Documentation for Renewal

  • Updated LDL-C levels showing continued need
  • Documentation of treatment adherence
  • Any changes in clinical status
  • Confirmation that alternative therapies remain inappropriate

Counterforce Health helps patients and providers streamline the renewal process by automatically tracking authorization expiration dates and preparing renewal documentation that aligns with payer requirements.

Costs and Financial Assistance

Expected Costs

Evkeeza's wholesale acquisition cost is approximately $450,000 per year (weight-based dosing). Your out-of-pocket cost depends on your specific plan's specialty tier coverage.

Financial Assistance Options

Manufacturer Support:

  • Evkeeza Copay Program - May reduce copays for eligible commercially insured patients
  • Patient assistance programs for uninsured or underinsured patients

Foundation Grants:

  • National Organization for Rare Disorders (NORD)
  • Patient Access Network Foundation
  • HealthWell Foundation

Illinois State Resources

Illinois expanded Medicaid may cover Evkeeza for eligible patients. Contact Illinois Department of Human Services for eligibility information.

Illinois-Specific Appeal Rights

Illinois provides some of the strongest patient protection laws in the country for insurance appeals:

Key Illinois Protections

  • Fast external review timelines: 5 business days for IRO decision (faster than most states)
  • No cost to patients for external review process
  • Binding decisions: Insurance companies must comply with favorable external review decisions
  • Consumer assistance: Illinois Attorney General's Health Care Helpline (1-877-305-5145)

When to Contact State Regulators

Contact the Illinois Department of Insurance if:

  • Aetna fails to meet state-mandated timelines
  • You believe the denial lacks medical merit
  • You need help understanding your appeal rights

Quick Reference Checklist

Before Submitting:

  • HoFH diagnosis confirmed (genetic or clinical)
  • Recent LDL-C levels documented
  • Prior therapy failures documented
  • Aetna form completed fully
  • All supporting documents attached

Submission:

  • Fax to 1-888-267-3277 (preferred)
  • Keep fax confirmation receipt
  • Follow up within 7 days

If Denied:

  • Request peer-to-peer review immediately
  • File internal appeal within 60 days
  • Consider external review if internal appeal fails
  • Contact Illinois DOI for assistance if needed

Frequently Asked Questions

Q: How long does Aetna prior authorization take in Illinois? A: Standard requests take 30-45 business days. Expedited requests for urgent medical needs are processed within 72 hours. Illinois regulations require faster processing than many other states.

Q: What if Evkeeza is not on Aetna's formulary? A: You can request a formulary exception by demonstrating medical necessity and providing evidence that formulary alternatives are inappropriate for your specific case.

Q: Can I use any pharmacy for Evkeeza? A: Most Aetna plans require use of CVS Specialty Pharmacy for specialty medications like Evkeeza. Confirm this requirement when verifying your benefits.

Q: Does step therapy apply if I tried therapies outside Illinois? A: Yes, documentation of prior therapy trials from any location is typically accepted, as long as the records are complete and demonstrate adequate trials or contraindications.

Q: What happens if I miss the appeal deadline? A: Illinois allows 60 days for internal appeals and 30 days for external review requests. Missing these deadlines may forfeit your appeal rights, but you can always submit a new prior authorization request with additional supporting documentation.

Q: Can a nurse practitioner or PA prescribe Evkeeza? A: Yes, but check with Aetna whether they have specific requirements for prescriber credentials or specialty training for HoFH treatments.

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Our platform ingests denial letters, plan policies, and clinical notes, then identifies the denial basis and drafts point-by-point rebuttals aligned to each plan's specific requirements. For complex cases like Evkeeza approvals, we help ensure your submission includes all required clinical facts, proper citations, and operational details that payers expect.

Disclaimer: This guide provides general information about insurance processes and should not be considered medical or legal advice. Always consult with your healthcare provider about treatment decisions and contact Aetna directly for the most current coverage policies and procedures. Insurance coverage varies by plan, and individual circumstances may affect approval decisions.

Illinois Department of Insurance Consumer Resources:

For additional support navigating insurance appeals, visit Counterforce Health or contact the Illinois Attorney General's Health Care Helpline at 1-877-305-5145.

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