How to Get Kesimpta (Ofatumumab) Covered by Aetna (CVS Health) in Michigan: Complete Prior Authorization and Appeals Guide
Quick Answer: Getting Kesimpta Covered by Aetna (CVS Health) in Michigan
Aetna (CVS Health) requires prior authorization for Kesimpta (ofatumumab) in Michigan, typically after failure of 2-3 formulary disease-modifying therapies including an interferon or glatiramer acetate. Your neurologist must document relapsing MS diagnosis, prior therapy failures, hepatitis B screening, and up-to-date vaccinations. Submit through CVS Caremark portal with standard approval taking 30-45 days. If denied, you have 180 days for internal appeals and 127 days for Michigan DIFS external review. Start today: Contact your neurologist to gather prior therapy records and schedule hepatitis B screening.
Table of Contents
- Is Kesimpta Covered by Aetna (CVS Health)?
- Prior Authorization Process
- Timeline and Deadlines
- Clinical Requirements
- Cost and Financial Assistance
- Denials and Appeals in Michigan
- Renewal Requirements
- Specialty Pharmacy Coordination
- Troubleshooting Common Issues
- FAQ
Is Kesimpta Covered by Aetna (CVS Health)?
Kesimpta (ofatumumab) is typically covered by Aetna (CVS Health) plans for FDA-approved indications, but requires prior authorization for all members. The medication is indicated for relapsing forms of multiple sclerosis in adults, including:
- Clinically isolated syndrome (CIS)
- Relapsing-remitting multiple sclerosis (RRMS)
- Active secondary progressive multiple sclerosis (SPMS)
Coverage varies by plan type:
- Commercial plans: Usually covered on specialty tier with step therapy requirements
- Medicare Advantage: Covered with similar PA criteria
- Medicaid plans: Coverage through Aetna Better Health varies by state contract
Note: Primary progressive MS is typically not covered as it's not an FDA-approved indication.
Prior Authorization Process
Who Submits the Prior Authorization?
Your prescribing neurologist or their office staff submits the PA request through the CVS Caremark portal or via fax. Patients cannot submit PAs directly.
Step-by-Step: Fastest Path to Approval
- Schedule neurologist consultation - Confirm relapsing MS diagnosis and review treatment history
- Complete hepatitis B screening - HBsAg and HBcAb tests required before first dose
- Update vaccinations - Complete all immunizations ≥2 weeks before treatment
- Gather documentation - Prior therapy records, MRI reports, lab results
- Neurologist submits PA - Through CVS Caremark provider portal with all supporting documents
- Track status - Monitor via portal; follow up if no response within 30 days
- If approved - Coordinate with CVS Specialty or assigned specialty pharmacy
Timeline and Deadlines
| Process | Standard Timeline | Expedited Timeline |
|---|---|---|
| Prior Authorization Decision | 30-45 days | ≤72 hours (urgent medical need) |
| Internal Appeal | 30 days for decision | 24-72 hours (expedited) |
| External Appeal (Michigan DIFS) | 60 days for decision | 72 hours (expedited) |
When to Request Expedited Review
Request expedited processing if:
- You're experiencing active MS relapses
- Current therapy is failing with new lesions or disability progression
- Delay would seriously jeopardize your health
Your neurologist must provide a letter stating that delay would harm your condition.
Clinical Requirements
Coverage at a Glance
| Requirement | What It Means | Documentation Needed |
|---|---|---|
| Diagnosis | Relapsing MS (ICD-10: G35) | Neurologist letter, MRI reports |
| Step Therapy | Trial of 2-3 formulary DMTs | Pharmacy records, failure documentation |
| Prescriber | Neurologist or consultation | DEA number, specialty verification |
| Safety Screening | HBV tests, vaccinations | Lab results, immunization records |
| Age Requirement | 18 years or older | Date of birth verification |
Required Laboratory Tests
Before starting Kesimpta, you must complete:
- Hepatitis B surface antigen (HBsAg) - Must be negative
- Hepatitis B core antibody (HBcAb) - If positive, requires specialist consultation
- Complete blood count with differential - Recent results
- Comprehensive metabolic panel - Recent results
- Quantitative immunoglobulins - If low, requires monitoring
Critical: Active hepatitis B infection (positive HBsAg) is an absolute contraindication to Kesimpta.
Step Therapy Requirements
Aetna typically requires documented failure of 2-3 formulary disease-modifying therapies, with at least one being:
- Interferon beta (Avonex, Betaseron, Extavia, Plegridy, Rebif)
- Glatiramer acetate (Copaxone, Glatopa)
Failure documentation must include:
- Dates of therapy
- Doses used
- Duration of treatment
- Reason for discontinuation (inadequate response, intolerance, contraindication)
Cost and Financial Assistance
Novartis Patient Support Programs
Alongside KESIMPTA offers comprehensive support:
- Copay assistance: Up to $18,000 annually for commercially insured patients
- Bridge Program: Free medication for up to 12 months during PA denials
- Benefits verification: Insurance coverage confirmation
Eligibility limitations:
- Not available for Medicare, Medicaid, or other government insurance
- Must have commercial insurance coverage
To enroll: Visit start.kesimpta.com or call patient support.
Alternative Financial Resources
- Prescription Hope: Kesimpta for $70/month (income-based eligibility)
- Michigan Medicaid: Lists Kesimpta as preferred drug list (PDL) preferred
- Foundation grants: Contact National MS Society for additional assistance programs
Denials and Appeals in Michigan
Common Denial Reasons & Solutions
| Denial Reason | How to Overturn |
|---|---|
| Insufficient step therapy | Provide detailed pharmacy records and failure documentation |
| Missing lab results | Submit complete HBV screening and safety labs |
| Non-formulary status | Request formulary exception with medical necessity letter |
| Quantity limits exceeded | Clarify dosing schedule (3 pens month 1, then 1 monthly) |
Michigan Appeals Process
Internal Appeals (First Step):
- Deadline: 180 days from denial date
- Timeline: 30 days for standard, 24-72 hours for expedited
- Submission: CVS Caremark member portal or written request
External Appeals (Michigan DIFS):
- Deadline: 127 days from final internal denial
- Timeline: 60 days for standard, 72 hours for expedited
- Submission: Online at michigan.gov/difs or call 877-999-6442
Tip: Michigan's 127-day external appeal deadline is longer than the federal 120-day standard, giving you extra time.
Required Documents for Appeals
- Copy of denial letter
- Medical records supporting necessity
- Prior therapy documentation
- Neurologist letter explaining medical necessity
- Current MRI reports showing disease activity
Renewal Requirements
Kesimpta prior authorizations typically require annual renewal. For reauthorization, provide:
- Clinical response documentation: Stable or improved MRI, reduced relapse rate
- Ongoing safety monitoring: Recent labs, no serious infections
- Continued medical necessity: Neurologist assessment of benefit
- Updated insurance information: Any plan changes
Specialty Pharmacy Coordination
Once approved, Kesimpta is typically dispensed through:
- CVS Specialty Pharmacy (for most Aetna CVS Health plans)
- Accredo Specialty Pharmacy (for some plans)
- Other contracted specialty pharmacies
Services included:
- Home delivery coordination
- Injection training and support
- 24/7 pharmacist consultation
- Refill reminders and adherence support
Your pharmacy will contact you within 48-72 hours of approval to coordinate delivery and training.
Troubleshooting Common Issues
Portal and System Problems
CVS Caremark portal down?
- Call provider services: 1-866-785-5714
- Submit via fax as backup (verify current fax with CVS)
Missing forms or documents?
- Download current PA forms from CVS Caremark provider portal
- Request forms by calling provider services
Status check delays?
- Allow 2-3 business days for portal updates
- Call for status if no update after 30 days
Communication Issues
Need to speak with a decision-maker?
- Request peer-to-peer review with medical director
- Your neurologist can request direct physician consultation
Conflicting information?
- Always verify with CVS Caremark directly
- Get confirmation numbers for all phone interactions
FAQ
How long does Aetna CVS Health prior authorization take in Michigan? Standard PA decisions take 30-45 days. Expedited reviews for urgent medical needs are completed within 72 hours.
What if Kesimpta is non-formulary on my plan? Request a formulary exception with medical necessity documentation. Your neurologist must demonstrate why formulary alternatives are inappropriate.
Can I request an expedited appeal if denied? Yes, if the delay would seriously jeopardize your health. Your neurologist must provide a supporting letter explaining the urgency.
Does step therapy apply if I failed therapies outside Michigan? Yes, documented therapy failures from any location count toward step therapy requirements. Ensure you have complete pharmacy records.
What happens if I lose Aetna coverage during treatment? Contact Novartis patient support immediately. The Bridge Program may provide temporary medication while you transition coverage.
How do I check my appeal status? For internal appeals, use the CVS Caremark member portal. For external appeals, contact Michigan DIFS at 877-999-6442.
From our advocates: We've seen many Kesimpta denials overturned when patients provide comprehensive step therapy documentation and current MRI evidence of disease activity. The key is working closely with your neurologist to submit a complete initial request rather than appealing an incomplete one.
About Counterforce Health
Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals through evidence-based advocacy. Our platform analyzes denial letters and creates targeted rebuttals using the right clinical evidence and payer-specific requirements to maximize approval chances.
Sources & Further Reading
- Aetna Multiple Sclerosis Policy
- Michigan DIFS External Review Process
- CVS Caremark Provider Portal (verify current link)
- Kesimpta FDA Prescribing Information
- Alongside KESIMPTA Patient Support
Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and coverage criteria change frequently. Always verify current requirements with your insurer and consult your healthcare provider for medical decisions. For official Michigan insurance regulations and appeal procedures, contact the Michigan Department of Insurance and Financial Services at 877-999-6442.
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