By Counterforce Health Team in Kalydeco (ivacaftor) —

How to Get Kalydeco (ivacaftor) Covered by Aetna (CVS Health) in Illinois: Complete Guide to Forms, Appeals, and Approvals

Answer Box: Getting Kalydeco Covered by Aetna in Illinois

Fastest path to approval: Submit prior authorization through Aetna's Availity provider portal with genetic testing confirming a responsive CFTR mutation. Key requirement: Patient must have cystic fibrosis with mutations like G551D, R117H, or others on Aetna's covered list. First step today: Download the Kalydeco enrollment form from CVS Specialty and gather CFTR genotype test results. Illinois residents have strong appeal rights through the Illinois Department of Insurance if initially denied.

Table of Contents

  1. Verify Your Plan and Coverage Requirements
  2. Required Forms and Documentation
  3. Submission Portals and Process
  4. Fax Numbers and Mail Addresses
  5. CVS Specialty Pharmacy Enrollment
  6. Support Lines and Contact Numbers
  7. Illinois Appeals and External Review
  8. Common Denial Reasons and Solutions
  9. Cost Assistance Programs

1. Verify Your Plan and Coverage Requirements

Before starting your prior authorization, confirm these details:

Check if CVS Caremark manages your prescriptions: Most Aetna plans in Illinois use CVS Caremark as the pharmacy benefit manager. However, some HMO plans may use different PBMs. Verify on your member portal using your Aetna ID card.

Kalydeco Coverage Criteria for 2024:

  • Confirmed cystic fibrosis diagnosis
  • Genetic testing showing responsive CFTR mutation
  • Patient age 4 months or older
  • Cannot be used with other ivacaftor-containing medications
  • Initial authorization typically for 12 months
Note: Aetna requires FDA-cleared genetic testing if the patient's genotype is unknown.

2. Required Forms and Documentation

Prior Authorization Form

Download the current Aetna Illinois prior authorization form for Kalydeco or access through the Aetna provider forms page.

Required Documentation Checklist

  • Completed prior authorization form
  • CFTR genetic test results (FDA-cleared test preferred)
  • CF diagnosis confirmation with ICD-10 codes
  • Clinical notes from CF specialist
  • Previous treatment history (if applicable)
  • Current pulmonary function tests
  • Patient demographics and insurance information

CVS Specialty Enrollment

Complete the Kalydeco specialty enrollment form simultaneously with your PA request to avoid delays.

3. Submission Portals and Process

Primary method: Aetna Availity Provider Portal

  • Register for Availity access if not already enrolled
  • Upload all supporting documentation
  • Track submission status electronically
  • Average decision time: approximately 8.5 hours for Illinois commercial plans

Timeline Recommendations

  • Submit at least 2 weeks before desired start date
  • Allow extra time during peak periods (January-March)
  • Follow up within 3-5 business days if no acknowledgment received

4. Fax Numbers and Mail Addresses

Specialty Drug Prior Authorization

Fax: 1-866-249-6155 (for CVS Caremark specialty drugs)

Alternative Contacts by Plan Type

  • Commercial plans: 1-888-632-3862 (TTY: 711)
  • Medicare plans: 1-800-624-0756 (TTY: 711)
  • Illinois Medicaid: 1-866-329-4701 (TTY: 711) | Fax: 1-877-779-5234
Tip: Include a cover sheet with patient name, DOB, member ID, and "URGENT - Specialty Drug PA Request" for faster processing.

5. CVS Specialty Pharmacy Enrollment

Step-by-Step Enrollment Process

  1. Register online: Visit www.caremark.com and create account using your CVS Caremark Prescription ID from your Aetna card
  2. Complete specialty enrollment: Download and submit the Kalydeco enrollment form
  3. Provider coordination: Your prescriber must send the prescription and clinical documentation to CVS Specialty
  4. Verification: CVS Specialty will verify coverage and coordinate with Aetna for prior authorization if needed

Transfer Existing Prescription

If transferring from another pharmacy, contact CVS Specialty customer service and request your provider send prescription details with all prior authorization documentation.

6. Support Lines and Contact Numbers

For Patients

  • CVS Caremark Customer Service: 877-232-8128 (24/7)
  • Aetna Member Services: Number on back of your ID card
  • CVS Specialty Pharmacy: Contact number provided on enrollment forms

For Providers

  • Aetna Provider Services: 1-800-AETNA-RX (1-800-238-6279)
  • Specialty Drug Support: 1-866-814-5506
  • Prior Authorization Status: Available through Availity portal

What to Ask When Calling

  • Request your prior authorization reference number
  • Ask for specific denial reasons if applicable
  • Confirm all required documentation was received
  • Request expedited review timeline if medically urgent

7. Illinois Appeals and External Review

Illinois provides strong patient protection for insurance denials, with specific timelines and processes.

Internal Appeal Process

  1. Timeline: Must file within 180 days of denial
  2. Decision deadline: 15 business days for pre-service requests
  3. Expedited appeals: 24 hours for urgent medical needs

External Review Rights

After exhausting Aetna's internal appeals, Illinois law guarantees independent external review:

  • Who handles it: Illinois Department of Insurance
  • Timeline to request: Within 30 days of final internal denial (shorter than many states)
  • Decision timeline: 5 business days after reviewer receives all materials
  • Cost: Free to patients; insurers pay all fees
  • Contact: 877-850-4740 or submit to Office of Consumer Health Insurance, 320 W. Washington Street, Springfield, IL 62767

Illinois-Specific Advantages

  • Automatic external review: For medical necessity denials, external review is automatic unless you opt out
  • Specialist reviewers: Independent reviewer must be board-certified in relevant specialty
  • Binding decisions: If external reviewer approves coverage, Aetna must provide it
Important: Illinois' 30-day external review deadline is shorter than most states. Don't delay after receiving your final internal appeal denial.

8. Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Missing genetic testing Submit FDA-cleared CFTR mutation analysis Lab report showing responsive mutation
"Not medically necessary" Provide CF specialist letter with clinical rationale Pulmonary function tests, treatment history
Non-formulary status Request formulary exception Medical necessity letter, failed alternatives
Age restrictions Verify patient meets 4+ month requirement Birth certificate, current medical records
Step therapy requirements Document failed/inappropriate alternatives Treatment history, contraindication notes

Medical Necessity Letter Template

Your CF specialist should include:

  • Specific responsive CFTR mutation identified
  • Current CF symptoms and functional status
  • Why Kalydeco is appropriate for this genotype
  • Expected clinical benefits
  • References to FDA labeling and CF Foundation guidelines

9. Cost Assistance Programs

Manufacturer Support

  • Vertex Patient Services: Financial assistance programs available
  • Copay support: May reduce out-of-pocket costs for eligible patients
  • Contact: Check Vertex's official patient support website for current programs

Additional Resources

  • CF Foundation Compass: Care coordination and insurance navigation
  • Illinois Medicaid: Expanded coverage may provide alternative option
  • Patient advocate organizations: Can provide appeal assistance

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed responses. Their platform identifies the specific denial basis and drafts point-by-point rebuttals aligned with each payer's own rules, helping patients get medications like Kalydeco approved more efficiently.

Throughout this process, if you encounter repeated denials or need assistance with complex appeals, services like Counterforce Health can help analyze your specific denial and create targeted appeal strategies based on Aetna's policies and Illinois regulations.

Sources & Further Reading

This guide is for informational purposes only and does not constitute medical advice. Coverage decisions depend on individual plan benefits and medical circumstances. For specific questions about your coverage, contact Aetna member services directly. For appeals assistance in Illinois, contact the Illinois Department of Insurance at 877-850-4740.

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