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

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

Answer Box: Getting Started

To get Eylea or Lucentis covered by Aetna CVS Health in Michigan: First, ensure your ophthalmologist tries bevacizumab (Avastin) unless contraindicated—Aetna requires step therapy. Submit prior authorization with OCT imaging showing retinal thickness ≥300 microns, visual acuity ≤20/40, and documented medical necessity. If denied, you have 180 days to appeal internally, then 127 days for Michigan DIFS external review. Start today: Ask your doctor to gather OCT scans, visual acuity records, and prior treatment history before submitting the PA request through CVS Specialty Pharmacy.

Table of Contents

  1. Aetna's Coverage Policy Overview
  2. FDA Indication Requirements
  3. Step Therapy and Medical Exceptions
  4. Quantity and Frequency Limits
  5. Required Diagnostic Documentation
  6. CVS Specialty Pharmacy Requirements
  7. Evidence for Medical Necessity
  8. Sample Medical Necessity Statement
  9. Appeals Process in Michigan
  10. Common Denial Reasons and Solutions
  11. Cost Savings and Patient Support
  12. FAQ

Aetna's Coverage Policy Overview

Aetna CVS Health covers both Eylea (aflibercept) and Lucentis (ranibizumab) for FDA-approved retinal conditions, but with significant restrictions. Both medications require prior authorization across all Aetna plan types—HMO, PPO, and Medicare Advantage.

Key Policy Points:

  • Eylea: Specialty tier drug requiring CVS Specialty Pharmacy dispensing
  • Lucentis: Non-preferred status with biosimilar alternatives preferred first
  • Step therapy mandatory: Bevacizumab (Avastin) or biosimilars must be tried before brand products
  • Documentation requirements: OCT imaging, visual acuity testing, and clinical justification required

You can find Aetna's current formulary and prior authorization requirements on their provider portal.

FDA Indication Requirements

Both Eylea and Lucentis are FDA-approved for specific retinal conditions. Aetna will only cover these medications for on-label uses:

Covered Indications:

  • Neovascular (wet) age-related macular degeneration (AMD)
  • Diabetic macular edema (DME)
  • Diabetic retinopathy in patients with DME
  • Macular edema following retinal vein occlusion

Documentation Required:

  • ICD-10 diagnosis codes matching FDA-approved indications
  • Clinical notes confirming active disease
  • Imaging evidence supporting the diagnosis

Off-label use may be covered through medical exception process with compelling clinical evidence and literature support.

Step Therapy and Medical Exceptions

Aetna's Step Therapy Requirements:

  1. First-line therapy: Bevacizumab (Avastin) - no prior authorization required
  2. Second-line options: Biosimilars (Byooviz, Cimerli) - prior authorization required
  3. Third-line: Brand products (Eylea, Lucentis) - prior authorization with step therapy documentation

Medical Exception Criteria:

  • Previous failure: Documented inadequate response after appropriate trial period
  • Intolerance: Adverse effects preventing continued use
  • Contraindication: Medical reason preventing safe use of preferred agent
  • Previous use: Patient successfully used requested drug within past 365 days
Tip: Document the specific reason for step therapy failure. "Patient preference" alone won't qualify for an exception.

How to Request Step Therapy Exception:

  • Submit via Aetna provider portal
  • Fax to CVS Specialty: 1-866-249-6155
  • Include detailed clinical rationale and supporting documentation

Quantity and Frequency Limits

Aetna imposes specific quantity and frequency restrictions for anti-VEGF injections:

Standard Limits:

  • Loading phase: Up to 3 monthly injections initially
  • Maintenance: Every 8-16 weeks depending on clinical response
  • Annual maximum: Typically 6-8 injections per eye per year

Exceeding Limits: If your treatment plan requires more frequent dosing, submit a formulary exception request with clinical justification.

Review Timeline:

  • Standard review: 72 hours
  • Expedited review: 24 hours (if delay would jeopardize health)

Required Diagnostic Documentation

Essential Documentation for Approval:

Requirement Specific Criteria Documentation Needed
Visual Acuity ≤20/40 or ≤20/50 in affected eye ETDRS chart results
OCT Imaging Central retinal thickness ≥300 microns OCT thickness maps with measurements
Fluid Documentation Subretinal or intraretinal fluid present OCT cross-sectional images
Disease Activity Evidence of active pathology Serial OCT comparisons

OCT Requirements:

  • High-quality images with adequate pupil diameter (≥3mm)
  • Central subfield thickness measurements
  • Clear documentation of fluid or anatomical changes
  • Baseline and follow-up scans for continued therapy

Visual Acuity Standards:

  • Best corrected visual acuity (BCVA) using standardized protocols
  • Documentation of vision loss attributable to treatable retinal pathology
  • Follow-up measurements to demonstrate treatment response

Counterforce Health's platform can help organize this complex documentation into targeted appeals that align with Aetna's specific requirements, turning denials into evidence-backed approvals through systematic analysis of payer policies.

CVS Specialty Pharmacy Requirements

Mandatory Specialty Pharmacy Routing: Both Eylea and Lucentis must be dispensed through CVS Specialty Pharmacy for Aetna members.

Process Steps:

  1. Prescriber sends prescription to CVS Specialty
  2. CVS Specialty initiates prior authorization
  3. Patient coordinates delivery to physician's office
  4. Administration occurs at approved site of care

CVS Specialty Contact:

  • Phone: 1-866-814-5506
  • Fax: 1-866-249-6155
  • TTY: 711

Site of Care Requirements:

  • Must be administered in physician office or outpatient facility
  • Home administration not covered
  • Ensure provider is in-network for administration codes

Evidence for Medical Necessity

Clinical Guidelines to Reference:

  • American Academy of Ophthalmology Preferred Practice Patterns
  • American Society of Retina Specialists guidelines
  • FDA prescribing information
  • Peer-reviewed studies supporting treatment approach

Key Evidence Points:

  • Natural history of untreated condition
  • Comparative effectiveness data
  • Safety profile considerations
  • Treatment response monitoring protocols

Documentation Best Practices:

  • Cite specific guideline recommendations
  • Include relevant study abstracts or summaries
  • Reference FDA labeling for dosing and monitoring
  • Document patient-specific factors affecting treatment choice

Sample Medical Necessity Statement

Template Language:

"Patient presents with [specific diagnosis] with documented visual acuity of [measurement] and OCT evidence of [specific findings including central retinal thickness]. Previous trial of bevacizumab resulted in [specific outcome/reason for discontinuation]. Current AAO guidelines recommend anti-VEGF therapy for this indication. [Requested drug] is FDA-approved for this condition and medically necessary to prevent further vision loss and optimize visual outcomes. Treatment plan includes [frequency] injections with OCT monitoring every [interval] to assess response."

Appeals Process in Michigan

Internal Appeal Process:

  1. Timeline: 180 days from denial to file internal appeal
  2. Standard review: 30-45 days for decision
  3. Expedited review: 72 hours for urgent cases

Michigan External Review Process: After internal appeal denial, Michigan residents can request external review through the Department of Insurance and Financial Services (DIFS).

External Review Timeline:

  • Filing deadline: 127 days after final internal denial
  • Standard review: 60 days maximum
  • Expedited review: 72 hours with physician certification of urgency

How to File External Review:

The external review is conducted by an Independent Review Organization (IRO) and the decision is binding on Aetna.

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Step therapy not completed Document bevacizumab failure/intolerance Treatment notes, adverse effects
Insufficient visual acuity loss Provide standardized BCVA measurements ETDRS chart results ≤20/40
Lack of OCT evidence Submit high-quality OCT with measurements Thickness maps showing ≥300 microns
Non-formulary status Request formulary exception Medical necessity letter
Frequency limits exceeded Clinical justification for increased dosing Treatment response documentation

Pro Tips:

  • Always include baseline and current measurements
  • Document specific reasons why preferred alternatives failed
  • Use Aetna's preferred terminology from their medical policies
  • Submit complete documentation packages to avoid delays

Cost Savings and Patient Support

Manufacturer Support Programs:

Additional Resources:

  • NeedyMeds database for foundation grants
  • State pharmaceutical assistance programs
  • Medicare Extra Help for Part D coverage

Eligibility Requirements:

  • Commercial insurance (not government programs)
  • Income restrictions may apply
  • Valid prescription for covered indication

FAQ

How long does Aetna prior authorization take in Michigan? Standard PA decisions are issued within 72 hours for specialty drugs. Complex cases may take up to 45 business days. Expedited requests are decided within 24 hours.

What if Eylea or Lucentis is non-formulary on my plan? You can request a formulary exception with medical necessity documentation. If denied, appeal through Michigan's external review process with DIFS.

Can I request an expedited appeal? Yes, if waiting for standard review could seriously jeopardize your health. Your treating physician must provide written certification of medical urgency.

Does step therapy apply if I've used these drugs before? If you've successfully used Eylea or Lucentis within the past 365 days, you may qualify for a step therapy exception based on previous use.

What happens if I miss the appeal deadline? Michigan allows 127 days for external review requests. Missing this deadline typically forfeits your right to external review, though you may have other options through state regulators.

Are there alternatives if insurance won't cover these drugs? Consider manufacturer patient assistance programs, clinical trials, or discussing alternative anti-VEGF options with your retina specialist.

From our advocates: We've seen many Michigan patients successfully obtain coverage after initial denials by ensuring their OCT documentation clearly shows central retinal thickness measurements and their physicians document specific reasons why bevacizumab wasn't appropriate. The key is thorough, organized documentation that directly addresses Aetna's published criteria.

Counterforce Health helps patients and clinicians navigate these complex coverage requirements by analyzing denial letters and payer policies to create targeted, evidence-based appeals. Our platform identifies the specific reasons for denial and drafts point-by-point rebuttals using the right clinical evidence and procedural requirements for your situation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and is not medical advice. Coverage policies and appeal procedures may change. Always consult current Aetna policy documents and speak with your healthcare provider about treatment options. For personalized assistance with insurance appeals, contact Michigan DIFS at 1-877-999-6442 or visit www.counterforcehealth.org.

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