By Counterforce Health Team in Eylea / Lucentis (aflibercept / ranibizumab) —

How to Get Eylea and Lucentis Covered by Aetna CVS Health in California: Complete Guide to Prior Authorization and Appeals

Answer Box: Getting Eylea/Lucentis Covered by Aetna CVS Health in California

To get Eylea (aflibercept) or Lucentis (ranibizumab) covered by Aetna CVS Health in California: First, ensure your ophthalmologist documents wet AMD, diabetic macular edema, or other FDA-approved diagnosis with OCT imaging and visual acuity measurements. Second, expect step therapy requiring bevacizumab (Avastin) trial first unless contraindicated. Third, submit prior authorization through provider portal or CoverMyMeds within California's mandated timelines (5 business days standard, 72 hours urgent). If denied, appeal within 180 days and utilize California's Independent Medical Review (IMR) for binding external review.

Table of Contents

Why California State Rules Matter

California's robust healthcare regulations significantly strengthen your position when seeking coverage for anti-VEGF injections like Eylea and Lucentis. The state's Department of Managed Health Care (DMHC) oversees most HMOs and managed care plans, while the California Department of Insurance (CDI) regulates other health policies.

These regulations interact with Aetna CVS Health's national policies in several key ways:

  • Faster decisions: California mandates 5 business days for standard prior authorization and 72 hours for urgent requests
  • Step therapy overrides: AB 347 requires clear exception processes when first-line treatments fail or cause harm
  • Continuity protections: Mid-year formulary changes can't disrupt ongoing therapy for up to 12 months
  • External review rights: Independent Medical Review (IMR) provides binding decisions when appeals are denied
Note: Self-funded employer plans (ERISA) may not be subject to all California regulations, though many voluntarily comply with state timelines.

Prior Authorization Turnaround Standards

California law establishes strict response deadlines that Aetna CVS Health must follow for specialty drug prior authorizations:

Request Type Timeline Criteria
Standard 5 business days Routine coverage determination
Expedited/Urgent 72 hours Life/health/function/severe pain risk
Renewal 5 business days Continuing therapy documentation

Expedited review criteria include situations where standard timing could:

  • Seriously jeopardize patient's life or health
  • Compromise ability to regain maximum function
  • Subject patient to severe pain inadequately managed without the medication

If Aetna CVS Health fails to respond within these timeframes, the prior authorization request is deemed approved for the duration of the prescription under California law.

Step Therapy Protections

Under AB 347 of 2021, California requires health plans to grant step therapy exceptions when specific criteria are met. For Eylea and Lucentis, common override situations include:

Medical Exception Criteria:

  • Previous failure or intolerance to bevacizumab (Avastin)
  • Contraindication to preferred agent documented in medical records
  • Drug interaction with patient's current medications
  • Medical history indicating likely failure based on clinical factors

Required Documentation:

  • Detailed clinical notes showing diagnosis and prior treatments
  • OCT imaging demonstrating retinal pathology
  • Visual acuity measurements and treatment response history
  • Provider attestation of medical necessity

Healthcare providers must use accepted standards of medical practice when requesting exceptions, and health plans cannot deny based solely on cost considerations.

Continuity of Care Laws

California's continuity of care protections prevent disruption when Aetna CVS Health makes mid-year formulary changes affecting your Eylea or Lucentis therapy.

Key Protections:

  • Duration: Up to 12 months of continued coverage
  • Eligibility: Pre-existing provider relationship and active treatment
  • Request deadline: 30 days from formulary change notification
  • Processing time: 30 days standard, 15 days urgent, 3 days if risk of harm

To request continuity of care:

  1. Contact Aetna CVS Health immediately upon formulary change notice
  2. Provide documentation of current treatment regimen
  3. Submit provider statement confirming ongoing therapeutic relationship
  4. Include clinical justification for continued therapy

If your continuity of care request is denied, you can appeal internally and then request Independent Medical Review through the DMHC.

External Review & Complaints

California's Independent Medical Review (IMR) system provides binding external review when Aetna CVS Health denies coverage for medical necessity reasons.

IMR Eligibility:

  • Treatment denied as not medically necessary
  • Experimental/investigational designation disputes
  • Emergency or out-of-network service disagreements
  • Must exhaust internal appeals first (or wait 30 days)

Success Rates and Timelines:

  • Standard IMR: 45 days for decision
  • Expedited IMR: 72 hours for urgent cases
  • Overturn rate: Approximately 11% for specialty drugs (2025 Q1 data)

Filing Process:

  1. Complete internal appeal with Aetna CVS Health
  2. Request IMR through DMHC website or call 888-466-2219
  3. Submit supporting medical records and provider statements
  4. Await independent physician review and binding decision
From our advocates: We've seen the strongest IMR outcomes when providers submit comprehensive documentation including OCT scans, treatment response data, and explicit citations to FDA labeling or specialty society guidelines. The key is demonstrating medical necessity with objective evidence rather than general statements.

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient/Clinic)

  • Insurance card and member ID
  • Complete ophthalmology records including OCT imaging
  • Visual acuity measurements and treatment history
  • ICD-10 diagnosis codes (H35.32 for wet AMD, E11.311 for diabetic macular edema)

2. Verify Coverage Requirements (Clinic Staff)

  • Check Aetna CVS Health formulary status
  • Confirm prior authorization requirements
  • Review step therapy protocols
  • Timeline: Same day via provider portal

3. Document Medical Necessity (Ophthalmologist)

Include in clinical notes:

  • Specific FDA-approved indication
  • Anatomic and visual acuity criteria met
  • Previous treatment failures or contraindications
  • Dosing rationale and monitoring plan

4. Submit Prior Authorization (Clinic)

  • Use Aetna provider portal or CoverMyMeds platform
  • Include all supporting documentation
  • Mark as urgent if criteria met
  • Timeline: 5 business days standard, 72 hours urgent

5. Follow Up on Decision (Patient/Clinic)

  • Track submission status through portal
  • Request peer-to-peer review if initial denial
  • Prepare appeal documentation if needed
  • Timeline: Contact if no response within mandated timeframes

6. File Internal Appeal if Denied (Patient)

  • Submit within 180 days of denial
  • Include additional clinical evidence
  • Request expedited review if urgent
  • Timeline: 30 days for standard, 72 hours for urgent appeals

7. Request IMR if Appeal Denied (Patient)

  • File through DMHC within 6 months
  • Provide comprehensive medical records
  • Await binding independent review
  • Timeline: 45 days standard, 72 hours expedited

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
Step therapy not completed Request medical exception Prior treatment records, contraindication notes
Insufficient diagnosis documentation Submit comprehensive records OCT scans, fluorescein angiography, visual fields
Frequency/quantity limits exceeded Provide treatment response data Injection logs, visual acuity improvements
"Not medically necessary" Cite FDA labeling and guidelines Published studies, specialty society recommendations
Non-formulary status Request formulary exception Comparative effectiveness data, prior failures

Appeals Playbook for Aetna CVS Health

Level 1: Internal Appeal

  • Deadline: 180 days from denial
  • Timeline: 30 days standard, 72 hours urgent
  • Submission: Member portal or written request
  • Required: Denial letter, additional clinical evidence, provider statement

Level 2: Independent Medical Review (California)

  • Deadline: 6 months from final internal denial
  • Timeline: 45 days standard, 72 hours expedited
  • Submission: DMHC website or phone 888-466-2219
  • Required: Complete medical records, treatment history, clinical justification

Expedited Appeals Available When:

  • Delay could seriously jeopardize health
  • Standard timing would impair recovery
  • Severe pain cannot be adequately managed

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned to each plan's specific requirements.

When to Escalate to State Regulators

Contact California regulators if Aetna CVS Health:

  • Exceeds mandated response timeframes
  • Fails to provide clear denial rationale
  • Doesn't follow step therapy exception processes
  • Violates continuity of care protections

DMHC Help Center: 888-466-2219 CDI Consumer Hotline: 800-927-4357

When filing complaints, include:

  • Member ID and policy information
  • Timeline of communications
  • Copies of denials and appeals
  • Documentation of regulatory violations

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take in California? Standard requests: 5 business days. Urgent requests: 72 hours. These are California-mandated maximums.

What if Eylea or Lucentis is non-formulary? Request a formulary exception with documentation of medical necessity. If denied, appeal and consider IMR.

Can I request expedited appeal for vision-threatening conditions? Yes. Conditions like wet AMD or diabetic macular edema with vision loss risk qualify for 72-hour expedited review.

Does step therapy apply if I've tried bevacizumab outside California? Yes, but document the trial and any failure/intolerance. Out-of-state records are valid for step therapy completion.

What's the success rate for specialty drug appeals in California? IMR overturns approximately 11% of specialty drug denials. Success increases with comprehensive documentation.

How does California's IMR differ from other states? California's IMR is binding on insurers, free to patients, and has strict timelines. Many other states lack these protections.

Can employer plans ignore California regulations? Self-funded ERISA plans may not be subject to all state laws, but many follow California timelines voluntarily.

What if I can't afford the medication while appealing? Explore manufacturer patient assistance programs, copay cards, and foundation grants while appeals are pending.

Sources & Further Reading:

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific guidance. Coverage policies and state regulations may change. For personalized assistance with complex appeals, consider working with organizations like Counterforce Health that specialize in insurance authorization processes.

Last updated: Information reflects current California regulations and Aetna CVS Health policies as of 2025. Verify current requirements with your specific plan.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.