By Counterforce Health Team in Kesimpta (ofatumumab) —

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

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

Fastest path to approval: Submit prior authorization through CVS Caremark with complete MS diagnosis documentation (ICD-10 G35), evidence of relapsing disease, and prescriber specialty verification. If denied, you have 4 years to appeal in Texas—much longer than the federal 180-day minimum. Start by calling CVS Caremark Prior Authorization at 1-800-294-5979 to verify current requirements and submission process.

First step today: Contact your neurologist to gather complete medical records, prior therapy documentation, and ensure they're prepared to submit a detailed medical necessity letter highlighting your relapsing MS phenotype and any previous treatment failures.

Table of Contents

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for Kesimpta CVS Caremark PA Department CVS Caremark PA Info
Formulary Status Varies by plan; often tier 3-4 specialty Your plan's drug formulary Aetna Formulary Lists
Prescriber Requirements Neurologist or MS specialist preferred PA form requirements (verify with CVS Caremark)
Diagnosis Documentation Relapsing MS with ICD-10 G35 Medical records ICD-10 MS Coding
Appeal Deadline (Texas) 4 years from denial date Texas insurance law Texas Appeal Rights
External Review Timeline 20 days standard, 72 hours urgent Texas Department of Insurance TDI Appeal Process

Coding That Gets Results

Medical vs. Pharmacy Benefit Paths

Kesimpta is self-administered subcutaneously, which means it typically falls under pharmacy benefit rather than medical benefit. This affects where you submit claims and which forms you'll need.

ICD-10 Coding for Multiple Sclerosis

Current code: G35 (Multiple sclerosis) remains valid through September 30, 2025. However, major changes are coming in 2026 that will require much more specific coding.

Important: Starting October 1, 2025, the general G35 code will no longer be accepted for billing. The 2026 ICD-10-CM update introduces 487 new diagnosis codes, with MS diagnoses requiring fifth or sixth characters to specify subtypes like RRMS, CIS, and SPMS.

Documentation words that support coding:

  • "Relapsing-remitting multiple sclerosis"
  • "Active lesions on MRI"
  • "Clinical relapses documented"
  • "Disease progression noted"
  • "Neurological symptoms consistent with MS"

Product Coding for Kesimpta

HCPCS/J-Code: J3490 (Injection, unclassified drugs) - most commonly used for Kesimpta NDC Numbers:

  • 66521-001-01 (prefilled pen, 20 mg/0.4 mL)
  • 66521-002-01 (prefilled syringe, 20 mg/0.4 mL)

Units calculation: Kesimpta 20 mg dose = 2 units of J3490 (1 unit = 10 mg)

Clean Request Anatomy

A complete prior authorization should include:

  • Patient demographics and Aetna member ID
  • Prescriber information (neurologist/MS specialist)
  • ICD-10 diagnosis code (G35)
  • NDC number (66521-001-01 or 66521-002-01)
  • Dosing schedule (monthly after initial 0, 1, 2-week loading)
  • Medical necessity documentation

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Requirements

  • Who: Patient or clinic staff
  • Action: Call CVS Caremark at 1-800-294-5979 to confirm current PA requirements
  • Timeline: Same day
  • Source: CVS Caremark PA Contact

2. Gather Complete Documentation

  • Who: Patient and prescribing neurologist
  • Documents needed: MS diagnosis records, MRI reports, prior therapy history, current symptoms
  • Timeline: 1-3 business days
  • Tip: Include documentation of relapsing disease pattern

3. Submit Prior Authorization

  • Who: Prescribing physician's office
  • Method: Electronic PA through Availity portal (preferred) or fax
  • Timeline: Submit Monday-Friday, 8 AM-6 PM CST
  • Source: CVS Caremark PA Portal

4. Follow Up on Decision

  • Timeline: Standard decisions within 30-45 days; expedited within 72 hours
  • Action: If denied, request detailed denial reason and prepare appeal
  • Source: Aetna Appeal Process

5. Appeal if Necessary

  • Timeline: Up to 4 years in Texas (much longer than federal requirement)
  • Method: Internal appeal first, then external review if needed
  • Source: Texas Extended Appeal Rights

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Not relapsing MS phenotype" Provide MRI evidence of active lesions, clinical relapse documentation Neurologist letter detailing relapsing pattern, MRI reports
"Missing baseline labs/vaccinations" Submit required screening results HBV screening, vaccination records, CBC
"Step therapy not met" Document prior DMT failures or contraindications Treatment history, adverse event reports
"Quantity limits exceeded" Justify dosing schedule per FDA labeling FDA prescribing information, dosing rationale
"Experimental/investigational" Cite FDA approval for relapsing MS FDA Kesimpta approval letter

Appeals Playbook for Texas

Internal Appeal Process

Timeline: 45 business days for standard decisions, 72 hours for expedited How to file:

  • Online through Aetna member portal
  • Mail to address on denial letter
  • Fax (confirm number with member services)

Required documents:

  • Original denial letter
  • Medical necessity letter from neurologist
  • Complete medical records supporting MS diagnosis
  • Documentation of prior therapy failures (if applicable)

External Review (IRO)

When available: After internal appeal denial or for urgent matters Timeline: 20 days standard, 72 hours for expedited review Cost: Up to $650 (may be waived for financial hardship) Deadline: 4 months from final internal denial

Texas Advantage: Texas provides significantly longer appeal windows than federal minimums, giving you more time to gather evidence and build a strong case.

State Resources

Texas Department of Insurance Consumer Helpline: 1-800-252-3439 Office of Public Insurance Counsel: 1-877-611-6742

Clinician Corner: Medical Necessity Essentials

Medical Necessity Letter Checklist

Problem statement:

  • Confirmed diagnosis of relapsing multiple sclerosis
  • ICD-10 code G35 (updating to more specific codes in 2026)
  • Clinical evidence of relapsing disease pattern

Prior treatments and outcomes:

  • List previous DMTs tried (if any)
  • Document reasons for discontinuation (efficacy failure, adverse events, contraindications)
  • Include dates and duration of prior therapies

Clinical rationale:

  • Why Kesimpta is appropriate for this patient
  • Expected clinical benefits
  • Monitoring plan

Guideline citations:

Documentation Best Practices

When preparing appeals, Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals. Their platform identifies denial reasons and drafts point-by-point rebuttals aligned to each plan's specific rules, significantly improving approval rates.

When to Escalate in Texas

Contact the Texas Department of Insurance if Aetna:

  • Violates appeal deadlines
  • Makes denials that ignore clear medical evidence
  • Commits procedural violations

File a complaint:

  • Online at TDI website
  • Call 1-800-252-3439
  • Include all denial letters, medical records, and correspondence

What to include:

  • Complete timeline of denial and appeals
  • Medical documentation supporting necessity
  • Evidence of procedural violations (if any)

FAQ

How long does Aetna CVS Health prior authorization take in Texas? Standard PA decisions take 30-45 days. Expedited reviews (for urgent medical situations) are completed within 72 hours.

What if Kesimpta is non-formulary on my plan? Request a formulary exception by demonstrating medical necessity and providing evidence that formulary alternatives are inappropriate or have failed.

Can I request an expedited appeal? Yes, if delaying treatment would jeopardize your health. Texas allows expedited external review concurrent with expedited internal appeals.

Does step therapy apply if I've tried other DMTs outside Texas? Yes, prior therapy history from any location counts. Provide complete documentation of previous treatments and outcomes.

What's the difference between internal and external appeals? Internal appeals are reviewed by Aetna staff. External appeals go to an independent organization contracted by Texas, providing an unbiased second opinion.

How much does external review cost in Texas? Up to $650, though this fee may be waived for financial hardship. The insurer pays for the IRO review itself.

From our advocates: We've seen cases where initial Kesimpta denials were overturned simply by providing more detailed documentation of the patient's relapsing disease pattern. MRI reports showing active lesions and neurologist notes documenting clinical relapses often make the difference. This is a composite example based on common successful appeal strategies, not a guarantee of outcomes.

For additional support navigating complex appeals, Counterforce Health specializes in turning insurance denials into evidence-backed appeals, helping patients access critical medications like Kesimpta more efficiently.

Sources & Further Reading

Medical Disclaimer: This information is for educational purposes only and is not medical advice. Always consult with your healthcare provider about treatment decisions. Insurance coverage varies by plan and individual circumstances. For official appeals assistance in Texas, contact the Texas Department of Insurance at 1-800-252-3439 or visit their website for current forms and procedures.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.