By Counterforce Health Team in Juxtapid (lomitapide) —

How to Get Juxtapid (Lomitapide) Covered by Aetna CVS Health in New Jersey: Prior Authorization, Appeals, and State Protections

Answer Box: Getting Juxtapid Covered by Aetna CVS Health in New Jersey

Juxtapid (lomitapide) requires prior authorization from Aetna CVS Health for homozygous familial hypercholesterolemia (HoFH). Key requirements: genetic HoFH diagnosis, failed trials of high-intensity statin + ezetimibe + PCSK9 inhibitor, LDL-C ≥100 mg/dL despite treatment, and REMS program enrollment. First step: Have your provider submit Aetna's Medical Exception/Prior Authorization form with complete clinical documentation. If denied, New Jersey's IHCAP external review through Maximus Federal Services provides binding appeal rights within 4 months.

Table of Contents

  1. Why New Jersey State Rules Matter
  2. Aetna CVS Health Prior Authorization Requirements
  3. New Jersey Turnaround Standards
  4. Step Therapy Protections in New Jersey
  5. Continuity of Care During Plan Changes
  6. External Review Through IHCAP
  7. Appeals Playbook for Aetna CVS Health
  8. Common Denial Reasons & Solutions
  9. Cost Assistance Options
  10. When to Contact State Regulators

Why New Jersey State Rules Matter

New Jersey's healthcare laws provide stronger patient protections than many other states, especially for specialty drugs like Juxtapid. The state's step therapy reform legislation and enhanced prior authorization requirements create specific rights that interact with Aetna CVS Health's policies.

Key New Jersey Advantages:

  • 24-hour urgent appeal decisions (vs. 72 hours in many states)
  • 180-day minimum authorization validity for chronic therapies
  • Medical exception criteria that insurers must honor
  • Binding external review through the Independent Health Care Appeals Program (IHCAP)
Note: These protections apply to fully-insured Aetna plans issued in New Jersey. Self-funded employer plans follow federal ERISA rules, which may differ.

Aetna CVS Health Prior Authorization Requirements

Juxtapid requires prior authorization for all Aetna CVS Health plans. Based on current Aetna policies, here's what your provider must document:

Coverage Requirements Table

Requirement Documentation Needed Where to Find It
HoFH Diagnosis Genetic testing showing mutations in two alleles (LDLR, APOB, PCSK9, LDLRAP1) OR untreated LDL-C >500 mg/dL or treated LDL-C ≥300 mg/dL plus xanthomas before age 10 Lab reports, genetic counselor notes
Step Therapy Failed combination of high-intensity statin + ezetimibe + PCSK9 inhibitor Medication history, prior therapy notes
Current LDL-C Lab results within 6 months showing LDL-C ≥100 mg/dL (≥70 mg/dL if ASCVD present) Recent lipid panel
REMS Enrollment Provider enrolled in Juxtapid REMS program REMS certification documentation
Safety Screening No moderate/severe hepatic impairment, contraception plan for women of childbearing potential Liver function tests, contraception counseling

Step-by-Step: Fastest Path to Approval

  1. Gather Documentation (Patient/Clinic): Collect genetic testing, medication history, recent labs, and REMS enrollment proof
  2. Complete PA Form (Provider): Submit Aetna's Medical Exception/Prior Authorization form
  3. Submit Request (Provider): Fax to Aetna or use provider portal (verify current submission method)
  4. Track Timeline (Patient): Standard decision within 30-45 days; urgent requests within 72 hours
  5. Appeal if Denied (Provider/Patient): Submit internal appeal within 180 days of denial
  6. External Review (Patient): File IHCAP appeal within 4 months if internal appeals fail
  7. Monitor Authorization (Patient): Ensure renewal requests are submitted 30 days before expiration

New Jersey Turnaround Standards

New Jersey's prior authorization reform laws set strict timelines that Aetna CVS Health must follow:

Standard Requests: 72 hours maximum Urgent Requests: 24 hours maximum
Chronic Therapy Authorization: Valid for minimum 180 days Plan Transition Grace Period: 60 days of continued coverage

Tip: If your request is urgent due to treatment interruption or clinical deterioration, have your provider clearly mark it as "URGENT" and provide clinical justification for the urgency.

Step Therapy Protections in New Jersey

New Jersey's step therapy override law requires Aetna CVS Health to grant exceptions when:

  • Contraindication exists: The required drug could cause harm
  • Expected ineffectiveness: Based on patient's clinical profile
  • Prior failure documented: All formulary options tried without success
  • Clinical stability: Patient stable on current therapy; switch would be inappropriate

Documentation Phrases That Help:

  • "Patient has documented intolerance to [specific drug] with [specific adverse effect]"
  • "Clinical contraindication exists due to [drug interaction/medical condition]"
  • "Patient achieved therapeutic stability on current regimen; disruption would compromise care"

Continuity of Care During Plan Changes

If you're switching to or from an Aetna CVS Health plan in New Jersey, continuity protections ensure uninterrupted Juxtapid access:

  • 60-day grace period for existing authorizations
  • Ongoing therapy protection for chronic conditions like HoFH
  • Transition coordination between old and new plans required

Action Steps:

  1. Notify both insurers about the plan change immediately
  2. Request transition of care authorization from new plan
  3. Ensure specialty pharmacy has updated insurance information
  4. Keep documentation of current authorization and prescription

External Review Through IHCAP

New Jersey's Independent Health Care Appeals Program provides binding external review for Aetna CVS Health denials.

IHCAP Eligibility

  • Fully-insured New Jersey plan (not self-funded employer plans)
  • Medical necessity denial or experimental/investigational determination
  • Internal appeals completed (or waived by plan)
  • Filed within 4 months of final denial

IHCAP Process

  1. Submit Application: Use Maximus IHCAP portal or mail forms
  2. Required Documents: IHCAP application, denial letters, medical records, $25 filing fee
  3. Review Timeline: 48 hours for urgent cases, 45 days for standard appeals
  4. Clinical Review: Independent physicians evaluate medical necessity using current standards
  5. Binding Decision: Aetna CVS Health must comply if overturned

IHCAP Contact Information:

  • Phone: 1-888-393-1062
  • Website: njihcap.maximus.com
  • NJ DOBI Hotline: 1-800-446-7467

Appeals Playbook for Aetna CVS Health

Internal Appeals Process

Appeal Level Timeline How to File Required Documents
First Level 180 days from denial Provider portal, fax, or mail Appeal form, additional clinical documentation
Second Level 60 days from first denial Same methods Enhanced documentation, peer-reviewed studies
Expedited 72 hours (urgent cases) Phone + written follow-up Urgency justification, clinical records

External Review Options

After completing Aetna's internal appeals:

  • IHCAP (New Jersey residents): Binding review by independent physicians
  • Independent Review Organization: For certain plan types
  • State Insurance Department: Complaint filing option

Common Denial Reasons & Solutions

Denial Reason How to Overturn Key Documentation
Insufficient HoFH documentation Submit genetic testing results and phenotypic criteria Genetic counselor report, family history, xanthoma photos
Step therapy not completed Document all prior failures with dates and reasons Medication history, adverse event reports, contraindication notes
Missing REMS enrollment Provide REMS certification Provider REMS enrollment confirmation
Experimental/investigational Cite FDA approval and clinical guidelines FDA label, HoFH treatment guidelines, peer-reviewed studies
Non-formulary status Request formulary exception Medical necessity letter, alternative failure documentation

Clinician Corner: Medical Necessity Letter Checklist

Essential Elements:

  • HoFH diagnosis with genetic/phenotypic confirmation
  • Complete prior therapy history with specific failure reasons
  • Current LDL-C levels and treatment goals
  • Safety monitoring plan including liver function surveillance
  • Citations from FDA labeling and HoFH guidelines
  • Patient-specific factors justifying Juxtapid over alternatives
From our advocates: "We've seen the strongest approvals when providers include a timeline showing exactly when each prior therapy was tried, why it failed, and current lab values. The more specific the clinical story, the harder it is for reviewers to deny."

Cost Assistance Options

Juxtapid's high cost makes financial assistance crucial:

Manufacturer Support:

  • Chiesi Global Rare Diseases patient assistance programs (verify current offerings)
  • Copay assistance for eligible patients
  • Bridge therapy during appeals process

Foundation Grants:

  • National Organization for Rare Disorders (NORD) assistance programs
  • HealthWell Foundation specialty drug grants
  • Patient advocate foundation copay relief

State Resources:

  • New Jersey pharmaceutical assistance programs
  • Hospital charity care programs
  • Social work consultation for additional resources

When to Contact State Regulators

Contact the New Jersey Department of Banking and Insurance if:

  • Aetna CVS Health violates state timeline requirements
  • Appeals process isn't followed properly
  • IHCAP decision isn't implemented
  • Discriminatory coverage practices suspected

Filing a Complaint:

  • Phone: 1-800-446-7467
  • Online complaint portal available
  • Include all denial letters, correspondence, and timeline documentation

Counterforce Health helps patients and providers navigate complex prior authorization challenges like Juxtapid approvals. Our platform analyzes denial letters, identifies specific coverage criteria, and generates evidence-backed appeals tailored to each payer's requirements. By automating the appeals process with the right clinical documentation and regulatory citations, we help turn insurance denials into approvals. Visit www.counterforcehealth.org to learn how we can support your coverage journey.

FAQ

Q: How long does Aetna CVS Health prior authorization take for Juxtapid in New Jersey? A: Standard requests: up to 72 hours under New Jersey law. Urgent requests: 24 hours maximum. Complex cases may take longer but must meet state deadlines.

Q: What if Juxtapid isn't on my Aetna formulary? A: Request a formulary exception using Aetna's medical exception process. Provide documentation showing medical necessity and why formulary alternatives are unsuitable.

Q: Can I appeal directly to New Jersey's external review? A: No, you must complete Aetna's internal appeal process first, unless the plan waives this requirement or fails to follow proper procedures.

Q: Does step therapy apply if I tried medications outside New Jersey? A: Yes, prior therapy trials from any location count toward step therapy requirements. Ensure your provider documents all previous treatments with dates and outcomes.

Q: What's the difference between urgent and standard appeals? A: Urgent appeals are for situations where delay could seriously jeopardize health. They receive 24-hour decisions vs. 72 hours for standard requests.

Q: How much does IHCAP external review cost? A: $25 filing fee for patients. All other costs are covered by the insurance plan, regardless of the outcome.

Sources & Further Reading

This guide is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and clinical circumstances. For specific coverage questions, contact your Aetna CVS Health member services or consult with your healthcare provider. For assistance with appeals and regulatory issues in New Jersey, contact the Department of Banking and Insurance at 1-800-446-7467.

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