By Counterforce Health Team in Kesimpta (ofatumumab) —

How to Get Kesimpta (Ofatumumab) Covered by Aetna CVS Health in Illinois: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Kesimpta Covered by Aetna CVS Health in Illinois

Kesimpta (ofatumumab) requires prior authorization from Aetna CVS Health for relapsing multiple sclerosis. Submit through the CVS Specialty Pharmacy portal with neurologist prescription, documented prior DMT failures, HBV screening, and vaccination records. Standard review takes 30-45 days; expedited review 72 hours. If denied, you have 180 days for internal appeals, then 4 months for Illinois external review through the Illinois Department of Insurance. Start by calling CVS Caremark at 1-800-294-5979 to verify your plan's specific requirements.

Table of Contents

  1. Verify Your Plan and Find the Right Forms
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Online Access
  4. Fax Numbers and Mailing Addresses
  5. CVS Specialty Pharmacy Setup
  6. Support Phone Lines and What to Ask
  7. Illinois Appeals and External Review
  8. Update Schedule for Forms and Policies

Verify Your Plan and Find the Right Forms

Before starting your Kesimpta prior authorization, confirm your Aetna CVS Health plan details. Not all Aetna plans use CVS Caremark for specialty drugs, and requirements vary between fully insured and self-funded employer plans.

First Steps:

  1. Call the number on your insurance card to verify specialty pharmacy benefits
  2. Ask specifically about Kesimpta's formulary tier and PA requirements
  3. Confirm whether you need step therapy documentation (prior DMT failures)
Note: Illinois residents with Aetna plans typically use CVS Caremark for specialty medications, but some employer plans may have different arrangements.

Coverage Requirements at a Glance

Requirement Details Where to Find Source
Prior Authorization Required for all plans CVS Caremark portal Aetna Specialty Pharmacy Guide
Formulary Tier Typically Tier 3-4 specialty Member portal or formulary PDF 2025 Aetna Specialty Drug List
Step Therapy Prior DMT trials required Medical policy documents Aetna MS Policy
Quantity Limits 3 pens first month, 1 monthly after Pharmacy benefits summary Aetna Quantity Limits
Prescriber Requirements Neurologist or consultation PA form requirements CVS Caremark PA guidelines

Prior Authorization Forms and Requirements

Aetna CVS Health uses standardized PA forms for Kesimpta, but the specific form version updates regularly. Always download the current version from the CVS Caremark provider portal.

Required Documentation Checklist

Clinical Information:

  • ✓ Confirmed relapsing MS diagnosis (ICD-10: G35)
  • ✓ Evidence of disease activity (recent relapses, MRI progression)
  • ✓ Neurologist prescription or consultation notes
  • ✓ HBV screening results (HBsAg, anti-HBc)
  • ✓ Current vaccination status

Prior Therapy Documentation:

  • ✓ List of previous DMTs tried with dates and durations
  • ✓ Reasons for discontinuation (efficacy failure, side effects, intolerance)
  • ✓ Pharmacy records showing prior fills
  • ✓ Clinical notes documenting treatment outcomes
Clinician Corner: Your medical necessity letter should reference FDA labeling for relapsing MS and include specific clinical markers like EDSS scores, relapse frequency, and MRI findings. Cite the American Academy of Neurology MS guidelines when justifying treatment choice.

Common Denial Reasons and How to Address Them

Denial Reason Documentation to Include Appeal Strategy
Step therapy not met Pharmacy records, clinic notes with prior DMT outcomes Emphasize specific failures: relapses, side effects, contraindications
Not medically necessary Recent MRI, relapse history, EDSS progression Include peer-reviewed evidence supporting early aggressive treatment
Missing safety screening HBV labs, vaccination records Submit complete lab panel with interpretation
Prescriber qualifications Neurologist credentials, consultation notes Provide board certification info or specialist referral

Submission Portals and Online Access

CVS Caremark operates the primary portal for Aetna specialty drug PAs. Providers need separate registration from the general Aetna provider portal.

CVS Caremark Provider Portal

  • URL: specialty.cvshealth.com (provider registration required)
  • Features: PA submission, status tracking, formulary lookup
  • Turnaround: Electronic submissions typically process faster than fax

Patient Access Options

  • Aetna Member Portal: View PA status and appeal rights
  • CVS Specialty App: Track prescription status and delivery
  • Phone Verification: Call CVS Specialty at 1-800-238-7828
Tip: Electronic submissions through the CVS portal allow real-time status tracking and faster processing than fax submissions.

Fax Numbers and Mailing Addresses

When portal access isn't available, use these verified contact methods for PA submissions:

Primary Fax Numbers

  • CVS Caremark PA Fax: 1-866-255-7569 (verify current number when calling)
  • Aetna Specialty Pharmacy: 1-866-782-2779 for fax number confirmation

Cover Sheet Requirements

Include these details on every fax:

  • Patient name and Aetna member ID
  • Prescriber name and NPI
  • "URGENT: Kesimpta PA Request" in subject line
  • Total page count
  • Return fax number for confirmation
Important: Fax numbers can change. Always verify the current submission fax when calling CVS Caremark or Aetna member services.

CVS Specialty Pharmacy Setup

Once PA is approved, Kesimpta must be dispensed through CVS Specialty Pharmacy for most Aetna plans. The onboarding process includes clinical consultation and injection training.

Transfer Process Steps

  1. Prescription Transfer: Call 1-800-238-7828 with current pharmacy information
  2. Clinical Intake: CVS pharmacist reviews medical history and drug interactions
  3. Delivery Setup: Schedule delivery to home or clinic
  4. Injection Training: Phone or video consultation for pen injector technique
  5. Ongoing Support: Monthly check-ins and refill coordination

Illinois CVS Specialty Locations

  • Primary: CVS Specialty Pharmacy (Monroeville, PA) - serves Illinois members
  • Local Support: Contact 1-800-238-7828 for Illinois-specific delivery options

Alternative Specialty Pharmacies

If your plan allows pharmacy choice:

  • Northwestern Medical Specialty Pharmacy (Chicago): 1-312-926-9365
  • Rush Specialty Drug Solutions (Chicago): 1-312-942-3444

Support Phone Lines and What to Ask

Having the right contact information saves time when navigating PA requirements and appeals.

Key Phone Numbers

Contact Phone Number Best For Hours
CVS Caremark 1-800-294-5979 PA status, formulary questions Mon-Fri 8AM-6PM CST
Aetna Member Services Number on insurance card Benefits verification, appeal rights 24/7
CVS Specialty 1-800-238-7828 Prescription transfer, delivery Mon-Fri 8AM-8PM ET
Illinois DOI Consumer Line 1-877-527-9431 Appeal guidance, external review Business hours

Phone Script for PA Status Check

"I'm calling about a prior authorization for Kesimpta, generic name ofatumumab, for my multiple sclerosis. My member ID is [number]. Can you tell me the current status and what additional information is needed?"

Follow-up questions:

  • What specific clinical documentation is missing?
  • Can you schedule a peer-to-peer review with my neurologist?
  • What's the timeline for a decision?
  • If denied, what are my appeal options?

Illinois Appeals and External Review

Illinois provides strong consumer protections for insurance denials, including binding external review by independent physicians.

Internal Appeal Process (Aetna)

  • Deadline: 180 days from denial notice
  • Timeline: 30 days standard, 72 hours expedited
  • Submission: Aetna member portal, mail, or fax
  • Required: Denial letter, new clinical evidence, updated physician letter

Illinois External Review

After exhausting Aetna's internal appeals, Illinois residents can request independent external review.

Key Details:

  • Deadline: 4 months from final internal denial (not 30 days as in some states)
  • Cost: Free to consumers
  • Timeline: 30 days for standard review
  • Decision: Binding on Aetna if upheld

Filing Process:

  1. Download Illinois External Review Form
  2. Include medical records and denial correspondence
  3. Submit to Illinois Department of Insurance
  4. Independent physician reviews case within 30 days
Illinois-Specific Advantage: The state's external review process has physician reviewers with MS expertise, and decisions are binding on insurers.

When to Request Expedited Review

  • Delay would jeopardize health or function
  • Ongoing treatment interruption
  • Physician certifies urgency

Expedited appeals receive decisions within 72 hours for internal appeals and 24-72 hours for external review.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned to the insurer's own rules, pulling the right medical citations and clinical evidence. For complex cases like Kesimpta appeals, having expert support can significantly improve approval chances.

Update Schedule for Forms and Policies

Insurance policies and forms change regularly. Stay current with these update schedules:

Annual Updates (January)

  • Aetna formulary lists and tier placement
  • PA form versions and requirements
  • Copay and coverage limits

Quarterly Updates

  • Medical policy criteria
  • Step therapy requirements
  • Preferred pharmacy networks

Monthly Monitoring

  • Check CVS Caremark portal for form updates
  • Verify current fax numbers and submission addresses
  • Review any plan notifications about policy changes
Best Practice: Bookmark the Aetna provider portal and check monthly for updates to specialty drug policies.

Frequently Asked Questions

How long does Aetna CVS Health PA take for Kesimpta in Illinois? Standard review takes 30-45 days; expedited review for urgent cases takes 72 hours. Electronic submissions through the CVS portal typically process faster than fax.

What if Kesimpta is non-formulary on my plan? Request a formulary exception with documentation of medical necessity and prior therapy failures. Include peer-reviewed evidence supporting Kesimpta over formulary alternatives.

Can I request an expedited appeal if my current DMT is failing? Yes, if your neurologist certifies that delay would jeopardize your health. Document recent relapses or progression to support urgency.

Does Illinois step therapy apply if I failed DMTs in another state? Yes, out-of-state medical records are accepted. Provide pharmacy records and clinical notes documenting prior therapy trials and outcomes.

How much does Kesimpta cost with Aetna coverage? Specialty tier copays vary by plan, typically $50-200+ monthly. Check your benefits summary or call member services for exact costs.

What manufacturer support is available? Novartis offers the Bridge Program (free drug during PA/appeals) and patient assistance for eligible individuals. Visit the Kesimpta website for applications.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult your healthcare provider and insurance company for guidance specific to your situation. For additional support with insurance appeals, consider consulting with organizations like Counterforce Health that specialize in overturning coverage denials.

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