By Counterforce Health Team in Kesimpta (ofatumumab) —

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

Answer Box: Getting Kesimpta Covered by Aetna CVS Health in Pennsylvania

Kesimpta (ofatumumab) requires prior authorization from Aetna via CVS Caremark for relapsing multiple sclerosis treatment. Submit through the CVS Caremark portal or call 1-800-294-5979, including neurologist documentation of relapsing MS diagnosis, prior DMT failures, HBV screening, and recent MRI evidence. Standard decisions take 30-45 days; expedited reviews within 72 hours. If denied, use Pennsylvania's new external review program with a 50% overturn rate. First step: Call CVS Caremark today to verify your plan's formulary tier and download the PA form.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather What You Need
  4. Submit the Prior Authorization Request
  5. Follow-Up and Timeline Management
  6. If You're Asked for More Information
  7. If Your Request Is Denied
  8. Pennsylvania's External Review Advantage
  9. Renewal and Re-authorization
  10. Quick Reference Checklist

What This Guide Covers

This comprehensive guide helps Pennsylvania patients and their healthcare providers navigate Aetna CVS Health's prior authorization process for Kesimpta (ofatumumab), a monthly self-injected treatment for relapsing forms of multiple sclerosis.

Whether you're newly diagnosed or switching from another MS therapy, this guide provides the specific forms, documentation requirements, and timelines you need to get coverage approved. We'll also cover Pennsylvania's powerful new external review program, which has successfully overturned 50% of insurance denials in its first year.

Before You Start: Verify Your Coverage

Check Your Plan Type and Formulary Status

Call CVS Caremark at 1-800-294-5979 (Monday-Friday, 8 AM-6 PM CST) with your Aetna member ID to verify:

  • Formulary tier (typically Tier 3-4 specialty)
  • Step therapy requirements (prior DMT trials needed)
  • Quantity limits (3 pens first month, 1 monthly thereafter)
  • Site of care restrictions (specialty pharmacy dispensing)
Pennsylvania Advantage: Fully insured Aetna members in Pennsylvania are exempt from step therapy requirements under state law, which can streamline your approval process.

Confirm Your MS Diagnosis Qualifies

Kesimpta is FDA-approved for relapsing forms of MS in adults, including:

  • Clinically isolated syndrome (CIS)
  • Relapsing-remitting MS (RRMS)
  • Active secondary progressive MS (SPMS)

Primary progressive MS is not covered. Your neurologist must confirm a relapsing phenotype with ICD-10 code G35.

Gather What You Need

Required Documentation Checklist

Patient Information:

  • Aetna member ID and insurance card
  • Complete contact information
  • Date of birth and demographics

Clinical Documentation:

  • Neurologist letter confirming relapsing MS diagnosis (ICD-10: G35)
  • Recent MRI reports showing disease activity (new T2 or gadolinium-enhancing lesions)
  • Documentation of prior disease-modifying therapy trials, including:
    • Medication names and dates
    • Doses and duration of treatment
    • Reasons for discontinuation (inadequate response, intolerance, contraindications)

Laboratory Requirements:

  • Hepatitis B screening results (HBsAg, anti-HBc)
  • Complete vaccination status
  • Recent complete blood count

Treatment Plan:

  • Rationale for choosing Kesimpta over alternatives
  • Planned dosing schedule (20mg at weeks 0, 1, 2, then monthly)
  • Monitoring plan

Where to Find the PA Form

Download the current Aetna CVS Caremark Kesimpta prior authorization form through:

  • CVS Caremark provider portal (preferred method)
  • Phone request: 1-800-294-5979
  • Specialty pharmacy fax: 1-866-249-6155

Submit the Prior Authorization Request

Submission Methods

Method Contact Best For Processing Time
Electronic PA (ePA) CVS Caremark portal Fastest processing 24-48 hours to acknowledge
Fax 1-866-249-6155 (Specialty) Complete documentation packages 3-5 business days
Phone 1-800-294-5979 Urgent cases or questions Same day submission
Mail 1300 East Campbell Road, Richardson, TX 75081 Complex cases with extensive records 5-7 business days

Medical Necessity Letter Template

Your neurologist should include these key elements:

Opening: "I am writing to request prior authorization for Kesimpta (ofatumumab) for [Patient Name], a [age]-year-old with relapsing multiple sclerosis."

Diagnosis: Confirm relapsing MS phenotype with specific evidence of disease activity (clinical relapses, new MRI lesions, disability progression).

Prior Treatments: Document specific DMT failures with dates, doses, and reasons for discontinuation.

Clinical Rationale: Explain why Kesimpta is medically necessary, referencing FDA labeling and treatment guidelines.

Safety Considerations: Confirm HBV screening completed and patient is appropriate candidate.

Follow-Up and Timeline Management

Standard Processing Times

  • Acknowledgment: 1-2 business days
  • Standard decision: 30-45 days from complete submission
  • Expedited review: 72 hours (for urgent medical situations)

Weekly Follow-Up Script

"Hi, this is [Name] calling about prior authorization request #[Reference Number] for Kesimpta for patient [Name], member ID [Number]. Can you please provide a status update and let me know if any additional information is needed?"

Document each call: Date, time, representative name, reference number, and next steps.

If You're Asked for More Information

Common Requests and Responses

Request How to Respond Timeline
Additional MRI reports Submit most recent scan showing active lesions 5 business days
Detailed DMT history Provide pharmacy records or physician notes documenting prior failures 7 business days
Peer-to-peer review Schedule within 3 business days; prepare clinical summary 72 hours after call

Peer-to-Peer Review Preparation

If Aetna requests a peer-to-peer review, your neurologist should prepare:

  • Patient's complete MS history and current status
  • Specific evidence of relapsing disease activity
  • Documentation of prior DMT failures or contraindications
  • Clinical rationale for Kesimpta selection
  • References to FDA labeling and MS treatment guidelines

If Your Request Is Denied

Common Denial Reasons and Solutions

Denial Reason Solution Evidence Needed
Non-formulary status Request formulary exception Medical necessity letter + guidelines
Insufficient prior failures Document all previous DMT trials Pharmacy records + physician notes
Missing lab work Submit required screening results HBV panel + vaccination records
"Experimental" designation Emphasize FDA approval FDA label + prescribing information

Internal Appeal Process

Timeline: You have 180 days from the denial date to file an internal appeal.

How to Appeal:

  1. Online: Through your Aetna member portal
  2. Mail: Send to the address on your denial letter
  3. Fax: Use the number provided in your denial notice

Required Documents:

  • Copy of original denial letter
  • Additional medical records supporting medical necessity
  • Updated physician letter addressing specific denial reasons
  • Any new clinical evidence or guidelines

Pennsylvania's External Review Advantage

Pennsylvania launched an Independent External Review program in January 2024 that has proven remarkably effective for overturning insurance denials.

How Pennsylvania's Process Works

Eligibility: After receiving your "Final Adverse Benefit Determination" from Aetna's internal appeal process, you have four months to request external review.

Success Rate: In 2024, 50.1% of external reviews were decided in favor of patients, resulting in coverage for previously denied treatments.

Timeline:

  • Submit request: Online at pa.gov/reviewmyclaim or call 1-877-881-6388
  • Eligibility confirmation: Within 5 business days
  • Independent review: Decision within 45 days (72 hours for expedited)
  • Final decision: Binding on the insurance company
From Our Advocates: We've seen Pennsylvania patients successfully overturn Kesimpta denials through external review by submitting comprehensive clinical records and emphasizing the drug's FDA approval for relapsing MS. The key is thorough documentation of disease activity and prior treatment failures.

Important Limitations

Pennsylvania's external review applies only to commercial insurance (not self-funded employer plans). Check with your employer's HR department to confirm your plan type.

Renewal and Re-authorization

When to Start Your Renewal

Begin the re-authorization process 60-90 days before your current approval expires. Aetna typically authorizes Kesimpta for 12-month periods.

Renewal Documentation

Required for continuation:

  • Updated neurologist letter documenting treatment response
  • Recent MRI showing disease stability or improvement
  • Medication adherence records (≥85% compliance)
  • Any new safety monitoring results

Evidence of Treatment Success:

  • Reduction in relapse rate compared to pre-treatment
  • MRI stability (no new T2 or enhancing lesions)
  • Functional status maintenance or improvement
  • Good tolerability profile

Quick Reference Checklist

Before You Call Aetna CVS Health

  • Have member ID and policy information ready
  • Confirm you have relapsing MS diagnosis
  • Gather prior DMT failure documentation
  • Complete HBV screening and vaccinations

For Your Neurologist

  • Download current PA form from CVS Caremark
  • Prepare comprehensive medical necessity letter
  • Include recent MRI and lab results
  • Document specific prior treatment failures

After Submission

  • Get confirmation and reference number
  • Set weekly follow-up reminders
  • Prepare for potential peer-to-peer review
  • Know your appeal rights and deadlines

Counterforce Health specializes in helping patients navigate complex prior authorization and appeal processes for specialty medications like Kesimpta. Our platform analyzes denial letters and creates targeted, evidence-backed appeals that speak directly to payer policies and medical necessity criteria. By combining clinical expertise with payer-specific knowledge, we help turn insurance denials into approvals, ensuring patients get access to the treatments they need. Learn more about our services at www.counterforcehealth.org.

Sources & Further Reading

Medical Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Always consult with your healthcare provider about treatment decisions and work with your insurance company for coverage determinations. Coverage policies may vary by plan and change over time.

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