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

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

Answer Box: Getting Eylea/Lucentis Covered by Aetna in Washington

Aetna CVS Health requires prior authorization for both Eylea and Lucentis in Washington. Lucentis is non-preferred with biosimilar alternatives (Byooviz, Cimerli) required first. If denied, you have 21 days to file for external review through Washington's Office of Insurance Commissioner. Start today: Call Aetna at 1-877-238-6200 to confirm your plan's formulary status and request prior authorization forms.

Quick steps: 1) Gather OCT imaging and visual acuity records, 2) Document failed alternatives or contraindications, 3) Submit PA request with clinical justification, 4) If denied, appeal internally then request IRO review through OIC at 1-800-562-6900.

Table of Contents

When Alternatives Make Sense

Aetna CVS Health's 2025 formulary positions Lucentis as non-preferred, requiring patients to try biosimilar alternatives first. This step therapy approach aims to reduce costs while maintaining clinical effectiveness for conditions like wet AMD, diabetic macular edema, and diabetic retinopathy.

Clinical considerations for alternatives:

  • Biosimilars contain the same active ingredient as the reference drug
  • FDA requires biosimilars to demonstrate equivalent safety and efficacy
  • Switching between anti-VEGF agents is medically appropriate when response is inadequate
  • Some patients may have better tolerance or response to specific formulations

When alternatives may not be appropriate:

  • Previous adverse reactions to biosimilar components
  • Stable disease control on current therapy
  • Contraindications specific to preferred alternatives
  • Urgent clinical situations requiring immediate treatment

Aetna's Preferred Alternatives

Based on Aetna's 2025 specialty formulary, the preferred alternatives to Lucentis are:

Biosimilar Options

  • Byooviz (ranibizumab-nuna) - FDA-approved biosimilar to Lucentis
  • Cimerli (ranibizumab-eqrn) - FDA-approved biosimilar to Lucentis

Other Anti-VEGF Agents

  • Eylea (aflibercept) - Different mechanism, may require separate prior authorization
  • Bevacizumab (Avastin) - Off-label use, coverage varies by plan
Note: Eylea has its own prior authorization requirements and may not be automatically preferred over Lucentis in all situations.

Pros and Cons Overview

Treatment Advantages Considerations Access Factors
Byooviz/Cimerli Lower cost, preferred status, same active ingredient as Lucentis Limited long-term data compared to reference drug Typically covered with standard PA
Eylea Longer dosing intervals, different mechanism Higher cost, requires separate PA May need step therapy documentation
Bevacizumab Lowest cost, widely used off-label Not FDA-approved for eye conditions Coverage highly variable
Lucentis Extensive clinical data, FDA-approved Non-preferred status, higher cost-sharing Requires exception or appeal

Exception Strategy

When to request a formulary exception:

  • Documented intolerance to preferred biosimilars
  • Contraindications to alternative agents
  • Stable disease control on current Lucentis therapy
  • Clinical failure of preferred alternatives after adequate trial

Evidence that strengthens exceptions:

  • Detailed adverse event documentation from biosimilar trials
  • Ophthalmologist letter explaining clinical rationale
  • OCT imaging showing disease progression on alternatives
  • Visual acuity decline during alternative therapy
  • Published literature supporting specific patient population needs

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing payer policies and crafting evidence-backed rebuttals. Their platform helps identify the specific denial basis and provides targeted documentation strategies for ophthalmology medications like Eylea and Lucentis.

Coverage Requirements at a Glance

Requirement Eylea Lucentis Where to Find
Prior Authorization Required Required Aetna PA List
Formulary Status Specialty tier Non-preferred 2025 Formulary
Step Therapy May apply Biosimilars first Plan documents
Diagnosis Requirements FDA-approved indications FDA-approved indications Aetna Policy
Visual Acuity Documentation Required Required Clinical notes
OCT Imaging Recommended Recommended Medical records
Appeals Deadline (WA) 21 days 21 days OIC Guide

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Requirements

Who: Patient or clinic staff
Action: Call Aetna at 1-877-238-6200 to confirm formulary status
Timeline: Same day
Source: Aetna Member Services

2. Gather Clinical Documentation

Who: Healthcare provider
Action: Collect OCT imaging, visual acuity tests, diagnosis codes, prior treatment history
Timeline: 1-2 days
Required: FDA-approved indication documentation

3. Complete Prior Authorization Request

Who: Prescribing physician
Action: Submit PA form with clinical justification
Timeline: 2-3 business days for standard review
Form: Aetna PA Request

4. Document Step Therapy if Required

Who: Healthcare provider
Action: Provide evidence of biosimilar trial failure or contraindications
Timeline: Include with initial PA
Key: Specific adverse events or inadequate response

5. Submit to CVS Specialty Pharmacy

Who: Healthcare provider
Action: Fax completed request to 1-888-267-3277
Timeline: Same day submission
Follow-up: Confirm receipt within 24 hours

6. Track Decision Timeline

Who: Patient and provider
Action: Monitor for decision within 15 days (72 hours if urgent)
Timeline: Per Aetna policy
Escalation: Call if no response by deadline

7. Initiate Appeal if Denied

Who: Patient with provider support
Action: File internal appeal immediately, then external review if needed
Timeline: 21 days from denial in Washington
Contact: Washington OIC at 1-800-562-6900

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
Step therapy not completed Document biosimilar trial with specific outcomes Treatment dates, adverse events, efficacy measures
Insufficient clinical documentation Provide comprehensive medical records OCT reports, visual acuity logs, diagnostic imaging
Non-formulary status Request formulary exception with medical necessity Ophthalmologist letter, literature support
Experimental/investigational Cite FDA approval and clinical guidelines FDA labeling, professional society recommendations
Quantity/frequency limits exceeded Justify dosing based on clinical response Treatment response documentation, disease severity

Appeals Process in Washington

Washington state provides robust consumer protections for insurance denials. After exhausting Aetna's internal appeals, patients can request an Independent Review Organization (IRO) evaluation.

Internal Appeals (Required First)

  • Timeline: File within 180 days of denial
  • Process: Submit written appeal with supporting documentation
  • Decision: 30 days for standard, 72 hours for urgent
  • Contact: Use address/portal provided in denial letter

External Review (IRO)

  • Eligibility: Complete internal appeals first; out-of-pocket cost >$500
  • Timeline: File within 21 days of final internal denial
  • Process: Contact Washington OIC at 1-800-562-6900
  • Decision: 15 days standard, 72 hours urgent
  • Outcome: IRO decision is binding on Aetna
From our advocates: We've seen many ophthalmology denials overturned at the IRO level when patients provide comprehensive documentation of disease progression and failed alternatives. The key is having your retinal specialist write a detailed letter explaining why the specific anti-VEGF agent is medically necessary for your particular case, supported by recent imaging and visual field tests.

Washington-specific advantages:

  • No cost to patient for external review
  • Board-certified ophthalmologist reviews eye-related appeals
  • Strong state oversight of insurance practices
  • Binding decisions on insurers

Clinician Corner: Medical Necessity Documentation

Essential Elements for PA Success

Clinical History:

  • Specific diagnosis with ICD-10 codes
  • Visual acuity measurements (ETDRS preferred)
  • OCT findings with quantitative measures
  • Previous treatment responses and durations

Medical Necessity Justification:

  • FDA-approved indication alignment
  • Clinical guideline references (AAO, ASRS)
  • Patient-specific factors requiring this agent
  • Treatment goals and monitoring plan

Prior Authorization Checklist:

  • Completed Aetna PA form
  • Clinical notes documenting diagnosis
  • OCT imaging reports
  • Visual acuity testing results
  • Documentation of alternative therapy trials
  • Adverse event reports if applicable
  • Treatment response monitoring plan

Key Clinical Guidelines

Patient Support Programs

Manufacturer Programs

  • Eylea: Regeneron Patient Assistance Program
  • Lucentis: Genentech Access Solutions

Financial Assistance

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Individual manufacturer copay cards (verify insurance compatibility)

State Resources

FAQ

How long does Aetna prior authorization take in Washington? Standard decisions within 15 days; urgent cases within 72 hours. Washington law doesn't change Aetna's internal timelines, but provides additional appeal rights if deadlines aren't met.

What if Eylea is non-formulary on my plan? Request a formulary exception with clinical documentation. If denied, appeal through Aetna's process, then Washington's external review system.

Can I request expedited review for eye injections? Yes, if your ophthalmologist certifies that delay would jeopardize your vision or health. Both Aetna and Washington's IRO process offer expedited reviews.

Does step therapy apply if I was stable on Lucentis from another state? Document your treatment history and stability. Counterforce Health can help craft appeals emphasizing continuity of care principles that many payers recognize.

What's the difference between internal and external appeals? Internal appeals are reviewed by Aetna staff. External review involves an independent ophthalmologist not employed by Aetna, with decisions binding on the insurer.

How much does external review cost in Washington? Nothing. Washington covers the cost of IRO review for eligible cases.

Can I get help with the appeals process? Yes. Contact Washington's Office of Insurance Commissioner at 1-800-562-6900 for free assistance with appeals and understanding your rights.

What happens if I lose the external review? The IRO decision is final for insurance purposes, but you may still have legal options. Contact the OIC for guidance on next steps.

Sources & Further Reading

Disclaimer: This information is for educational purposes and should not replace professional medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for plan-specific requirements. For assistance with insurance appeals in Washington, contact the Office of the Insurance Commissioner at 1-800-562-6900.

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