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

How to Get Evkeeza (Evinacumab-dgnb) Covered by Aetna CVS Health in Georgia: Complete Appeals Guide

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

Evkeeza (evinacumab-dgnb) requires prior authorization from Aetna CVS Health for homozygous familial hypercholesterolemia (HoFH) patients in Georgia. To get approved: (1) Have your doctor submit a precertification request with HoFH diagnosis confirmation and prior lipid-lowering therapy documentation, (2) Allow 30-45 days for standard review (72 hours for urgent cases), (3) If denied, file an internal appeal within 180 days, then request external review through Georgia's Department of Insurance within 60 days of final denial. Start by asking your prescriber to complete Aetna's Evkeeza precertification form today.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timing and Deadlines
  4. Approval Criteria
  5. Costs and Copay Assistance
  6. Denials and Appeals in Georgia
  7. Renewal Requirements
  8. Specialty Pharmacy Coordination
  9. Troubleshooting Common Issues
  10. FAQ

Coverage Basics

Is Evkeeza covered by Aetna CVS Health? Yes, but it requires prior authorization for all patients with homozygous familial hypercholesterolemia (HoFH). Aetna covers Evkeeza as an adjunct therapy to other LDL-cholesterol-lowering treatments when medical necessity criteria are met.

Which Aetna plans cover it? Most Aetna commercial plans, Medicare Advantage, and Medicaid managed care plans include Evkeeza coverage, though formulary placement and cost-sharing vary by specific plan design.

Coverage at a Glance:

Requirement What It Means Where to Find It Source
Prior Authorization Must get approval before treatment Aetna Precertification List Aetna
HoFH Diagnosis Confirmed genetic or clinical diagnosis Medical records, genetic testing FDA Label
Step Therapy Trial of other lipid-lowering drugs first Pharmacy records, chart notes Aetna Policy
Age Requirement FDA-approved for ages 1+ Birth certificate, medical records FDA
Specialty Pharmacy Dispensed through CVS Specialty Automatic coordination CVS Health

Prior Authorization Process

Who submits the prior authorization? Your prescribing physician or their office staff must submit the precertification request to Aetna. Patients cannot submit these requests directly.

Step-by-Step: Fastest Path to Approval

  1. Doctor completes Evkeeza precertification form - Your physician fills out Aetna's specific Evkeeza form with clinical details
    • Timeline: 1-2 business days
    • Who does it: Prescriber's office
  2. Gather required documentation - Clinic compiles HoFH diagnosis confirmation, recent LDL-C levels, and prior therapy records
    • Timeline: 2-5 business days
    • Who does it: Medical records staff
  3. Submit via Availity portal - Most efficient submission method for Aetna prior authorizations
    • Timeline: Same day
    • Who does it: Clinic staff
  4. Aetna clinical review - Medical directors review against coverage criteria
    • Timeline: 30-45 days standard, 72 hours expedited
    • Who does it: Aetna
  5. Decision notification - Written determination sent to prescriber and patient
    • Timeline: 1-2 days after decision
    • Who does it: Aetna
  6. If approved, specialty pharmacy setup - CVS Specialty contacts patient for delivery coordination
    • Timeline: 3-5 business days
    • Who does it: CVS Specialty
  7. First infusion scheduled - Treatment begins at approved infusion center
    • Timeline: 1-2 weeks
    • Who does it: Patient and provider
Tip: Submit precertification at least two weeks before the planned start date to avoid treatment delays.

Timing and Deadlines

How long does Aetna prior authorization take? Standard decisions typically take 30-45 days from submission of complete documentation. Expedited reviews for urgent medical situations receive decisions within 72 hours.

When to request expedited review: If waiting for standard processing could seriously jeopardize your health or ability to regain maximum function. Your doctor must provide clinical justification for urgency.

Georgia-Specific Timeline for Appeals:

  • Internal Appeal Deadline: 180 days from denial date (65 days for Medicare plans)
  • External Review Deadline: 60 days from final internal appeal denial
  • External Review Decision: 30 business days (72 hours for expedited)

Approval Criteria

What documentation does Aetna require for Evkeeza approval?

Clinician Corner: Medical Necessity Letter ChecklistConfirmed HoFH diagnosis via genetic testing or clinical criteria (LDL-C >500 mg/dL, family history, physical findings)Current LDL-C levels demonstrating inadequate control despite treatmentPrior therapy documentation showing trials of maximally tolerated statin, ezetimibe, and PCSK9 inhibitor (unless contraindicated)Treatment goals and expected clinical outcomes with EvkeezaDosing rationale based on patient weight (15 mg/kg every 4 weeks)Monitoring plan for LDL-C response and safety parameters

Step therapy requirements: Patients typically must have tried and failed (or have contraindications to) conventional lipid-lowering therapies including:

  • High-intensity statin therapy
  • Ezetimibe
  • PCSK9 inhibitors (evolocumab or alirocumab)
  • LDL apheresis consideration (if available)

Age considerations: Evkeeza is FDA-approved for HoFH patients as young as 1 year old, with pediatric efficacy data showing 48% LDL-C reduction in children ages 5-11.

Costs and Copay Assistance

What will Evkeeza cost me? With Aetna coverage, your out-of-pocket costs depend on your specific plan's specialty drug benefits. Evkeeza has a wholesale acquisition cost of approximately $450,000 annually.

Manufacturer Copay Assistance: Georgia residents with commercial insurance may qualify for the myRARE Copay Assistance Program:

  • Eligibility: Commercial insurance required (Medicare/Medicaid excluded)
  • Coverage: Up to $25,000 per year in out-of-pocket costs
  • Typical patient cost: $0-$45 per treatment after assistance
  • How to enroll: Call 1-877-EVKEEZA (1-877-385-3392) or visit myRARE.com

Patient Assistance Program: Uninsured patients or those with denied coverage may qualify for free medication through myRARE if household income is below $100,000 or 500% of Federal Poverty Level.

Denials and Appeals in Georgia

Common denial reasons and how to address them:

Denial Reason How to Overturn Required Documentation
Insufficient HoFH documentation Submit genetic testing or clinical criteria Lab results, family history, physical exam findings
Missing prior therapy trials Document step therapy completion Pharmacy records, chart notes, intolerance documentation
"Not medically necessary" Provide clinical justification Medical necessity letter, treatment goals, monitoring plan
Quantity limits exceeded Justify weight-based dosing Height/weight documentation, dosing calculations

Appeals Playbook for Aetna CVS Health in Georgia:

  1. Internal Appeal (First Level)
    • Deadline: 180 days from denial date
    • How to file: Written request to address on denial letter
    • Required: Original denial, medical records, physician statement
    • Timeline: 30 days for decision (72 hours if expedited)
  2. External Review (Independent Review Organization)
Note: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to each plan's specific coverage criteria.

Renewal Requirements

When does Evkeeza authorization expire? Most Aetna prior authorizations for specialty medications are valid for 12 months, after which renewal is required.

What's needed for renewal?

  • Updated LDL-C levels showing continued need
  • Documentation of treatment response
  • Confirmation of ongoing HoFH diagnosis
  • Assessment of continued medical necessity

Renewal timeline: Submit renewal requests 30-60 days before expiration to avoid treatment interruption.

Specialty Pharmacy Coordination

Why was my prescription transferred to CVS Specialty? Aetna typically requires specialty medications like Evkeeza to be dispensed through their preferred specialty pharmacy network, primarily CVS Specialty.

What to expect from CVS Specialty:

  • Prior authorization coordination
  • Insurance benefit verification
  • Copay assistance program enrollment
  • Delivery scheduling and coordination
  • Clinical monitoring and support

CVS Specialty contact: Patients receive direct contact information once the prescription is transferred.

Troubleshooting Common Issues

Provider portal problems: If the Availity portal is unavailable, fax precertification requests to the number listed on your denial letter or Aetna's provider manual.

Missing forms: All current Aetna precertification forms are available on their provider website.

Delayed decisions: Contact Aetna Provider Services if standard review timelines are exceeded without communication.

Urgent situations: Always request expedited review when delays could compromise patient health, providing clinical justification for urgency.

FAQ

How long does Aetna CVS Health prior authorization take for Evkeeza in Georgia? Standard prior authorization decisions take 30-45 days, while expedited reviews for urgent medical situations are completed within 72 hours.

What if Evkeeza is non-formulary on my Aetna plan? Request a formulary exception by demonstrating medical necessity and providing documentation that formulary alternatives are inappropriate or ineffective for your HoFH.

Can I request an expedited appeal in Georgia? Yes, both internal appeals with Aetna and external reviews through Georgia's Department of Insurance offer expedited processing for urgent medical situations.

Does step therapy apply if I've tried other treatments outside Georgia? Yes, prior therapy documentation from any location is acceptable as long as you can provide pharmacy records or medical documentation of the trials and outcomes.

What happens if my Aetna appeal is denied? You have 60 days to request external review through Georgia's Department of Insurance, which provides an independent medical review at no cost to you.

Can my doctor do a peer-to-peer review with Aetna? Yes, physicians can request peer-to-peer consultations with Aetna medical directors to discuss complex cases and provide additional clinical context.

How do I check my Evkeeza prior authorization status? Providers can check status through the Availity portal, while patients can call the member services number on their insurance card.

What if I move from Georgia to another state? Contact Aetna to update your address and confirm any changes to coverage or appeal rights, as external review processes vary by state.

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to create compelling appeals that address each payer's specific coverage criteria, potentially saving months of back-and-forth communications.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan benefits and medical circumstances. Always consult your healthcare provider and insurance plan documents for personalized guidance. For specific appeals assistance, contact Counterforce Health or Georgia's Department of Insurance Consumer Services at 1-800-656-2298.

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