By Counterforce Health Team in Koselugo (selumetinib) —

How to Get Koselugo (selumetinib) Covered by Aetna (CVS Health) in California: Complete Prior Authorization Guide with Forms and Appeals

Answer Box: Getting Koselugo (selumetinib) Covered by Aetna (CVS Health) in California

Who's eligible: Pediatric patients (≥1 year) with neurofibromatosis type 1 (NF1) and symptomatic, inoperable plexiform neurofibromas. Fastest approval path: Submit prior authorization via CVS Caremark portal with complete NF1 documentation, baseline cardiac/eye exams, and surgical consultation confirming inoperability. Start today: Verify your Aetna plan is DMHC-regulated, gather NF1 diagnostic records, and download the Aetna CVS Health Koselugo PA form (verify with the source linked). If denied, California offers Independent Medical Review with high overturn rates for specialty drug denials.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Plan Verification
  3. Gather Required Documentation
  4. Submit the Prior Authorization Request
  5. Follow-Up and Tracking
  6. Typical Timelines in California
  7. If You're Asked for More Information
  8. If Denied: Appeals Process
  9. Renewal and Reauthorization
  10. Quick Reference Checklist
  11. FAQ

What This Guide Covers

This comprehensive guide helps patients, families, and clinicians navigate Aetna (CVS Health) prior authorization for Koselugo (selumetinib) in California. Koselugo is the only FDA-approved systemic therapy for pediatric patients with NF1 and symptomatic, inoperable plexiform neurofibromas.

Who this helps:

  • Parents of children with NF1 and plexiform neurofibromas
  • Pediatric oncologists and neurologists prescribing Koselugo
  • Patient advocates and care coordinators
  • Specialty pharmacy staff managing CVS Specialty enrollments

Expected outcomes: With complete documentation, most Koselugo requests meeting FDA criteria receive approval within 1-2 weeks. California's robust external review process provides strong backup options if initially denied.

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform helps patients and clinicians get prescription drugs approved by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned to each plan's specific requirements.

Before You Start: Plan Verification

Confirm Your Aetna Plan Type

Check your insurance card and member portal to identify:

  • Plan name: Look for "Aetna Health of California HMO," "Aetna CVS Health," or similar
  • Regulation type: Most California Aetna plans are DMHC-regulated, giving you access to Independent Medical Review
  • Pharmacy benefit manager: Usually CVS Caremark for specialty drugs like Koselugo

Coverage Verification

Requirement What to Check Where to Find It
Formulary status Is Koselugo covered? What tier? CVS Caremark formulary or member portal
Prior authorization Required for all Koselugo requests CVS Caremark PA requirements
Specialty pharmacy Must use CVS Specialty CVS Specialty enrollment required
Step therapy Rarely applies (Koselugo is first-line for NF1 PN) Plan documents
Tip: Call the member services number on your insurance card to confirm current Koselugo coverage and PA requirements for your specific plan.

Gather Required Documentation

Core Clinical Documentation

NF1 Diagnosis Proof:

  • Genetic test results showing NF1 mutation, OR
  • Clinical documentation of NIH criteria (café-au-lait spots, neurofibromas, family history, etc.)
  • ICD-10 code: Q85.01 (Neurofibromatosis, type 1)

Plexiform Neurofibroma Documentation:

  • Recent MRI or CT showing tumor locations and measurements
  • Clinical notes describing symptoms (pain, functional impairment, disfigurement)
  • Surgical consultation confirming tumors are inoperable due to vital structure involvement

Baseline Safety Requirements:

  • Echocardiogram with left ventricular ejection fraction (LVEF)
  • Comprehensive ophthalmologic examination
  • Baseline CPK and liver function tests
  • Growth charts and body surface area (BSA) calculation for dosing

Administrative Documents

  • Current Aetna insurance card (front and back)
  • Previous denial letters (if resubmitting)
  • Prior therapy documentation (surgeries, medications tried)

Submit the Prior Authorization Request

Step-by-Step Submission Process

1. Complete the CVS Specialty Enrollment Form

  • Download from CVS Specialty provider portal
  • Include all clinical documentation as attachments
  • Submit directly to CVS Specialty to initiate PA process

2. Submit Aetna CVS Health Koselugo PA Form

  • Access via CoverMyMeds (preferred method)
  • Alternative: Fax completed form to CVS Caremark PA department
  • Include comprehensive letter of medical necessity

3. Letter of Medical Necessity Checklist

  • Patient demographics and insurance information
  • Detailed NF1 diagnosis with criteria met
  • Plexiform neurofibroma characteristics and symptoms
  • Statement confirming tumors are symptomatic and inoperable
  • Prior treatment history and why alternatives are inadequate
  • Koselugo dosing plan based on BSA
  • Monitoring schedule (cardiac, ophthalmologic, laboratory)
Clinician Corner: Use the manufacturer's NF1 PN Letter of Medical Necessity template as your starting point, customizing with patient-specific details.

Follow-Up and Tracking

Monitoring Your Request

Within 48 hours: Confirm CVS Caremark received your submission

  • Call CVS Caremark PA department: 800-294-5979
  • Reference your submission confirmation number
  • Ask for expected decision timeline

Sample follow-up script: "I'm calling to check the status of a Koselugo prior authorization for [patient name], DOB [date]. The submission reference number is [number]. Can you confirm receipt and provide the expected decision date?"

What to Track

  • Submission date and confirmation number
  • CVS Caremark case reference number
  • Decision deadline based on California regulations
  • Any requests for additional information

Typical Timelines in California

Standard Prior Authorization Timeline

Step Timeline California Regulation
Initial submission Day 0 Submit complete packet
CVS Caremark review 24-72 hours DMHC requires 72-hour decisions for non-urgent pharmacy PA
Additional info request Up to 14 days If incomplete submission
Final decision 1-2 weeks total Must meet state timelines

Expedited Review

For urgent cases where delay could seriously jeopardize health:

  • Request expedited review in your PA submission
  • Decision required within 24-72 hours under California law
  • Include physician statement of medical urgency

If You're Asked for More Information

Common Information Requests

"Need more details on inoperability":

  • Provide detailed surgical consultation notes
  • Include imaging reports with radiologist interpretation
  • Explain specific risks if surgery were attempted

"Require additional NF1 documentation":

  • Submit genetic test results if available
  • Provide photos of café-au-lait spots or other clinical signs
  • Include family history documentation

"Need baseline monitoring results":

  • Ensure echocardiogram report includes specific LVEF value
  • Provide complete ophthalmology consultation report
  • Submit all required laboratory values
Note: CVS Caremark typically responds to additional information within 24-48 hours once received.

If Denied: Appeals Process

Level 1: Internal Appeal with Aetna

Timeline: You have 180 days from denial to file internal appeal

How to file:

  1. Call Aetna Member Services (number on insurance card)
  2. Request written appeal form or submit online via member portal
  3. Include enhanced medical necessity letter addressing specific denial reasons

Enhanced appeal documentation:

  • Point-by-point response to denial rationale
  • FDA labeling confirming Koselugo is only approved systemic therapy for NF1 PN
  • Clinical literature supporting use in pediatric population
  • Specialist letter emphasizing lack of alternative treatments

Level 2: California Independent Medical Review (IMR)

If Aetna upholds the denial, California residents can request Independent Medical Review through the Department of Managed Health Care.

IMR Process:

  • Free to patients - no cost for external review
  • Independent physician experts review medical records
  • Binding decision - Aetna must comply if IMR overturns denial
  • High success rate for specialty drug appeals when medically justified

IMR Timeline:

  • Standard IMR: Decision within 30-45 days
  • Urgent IMR: Decision within 7 days or less

How to request IMR:

  1. Download IMR application from DMHC website
  2. Include all medical records and Aetna correspondence
  3. Submit within required timeframe after final internal denial

When patients need help navigating complex appeals, Counterforce Health provides specialized support in building evidence-backed appeals that address payer-specific criteria and procedural requirements.

Renewal and Reauthorization

When to Start Renewal Process

Begin reauthorization 60-90 days before current approval expires:

  • CVS Specialty typically sends renewal reminders 30 days prior
  • Gather updated clinical documentation showing continued benefit
  • Schedule required monitoring exams (echo, eye exam) before renewal submission

Renewal Documentation Requirements

Clinical Response Evidence:

  • Interval MRI showing tumor response or stability
  • Clinical notes documenting symptom improvement or stabilization
  • Pain scores, functional assessments, quality of life measures

Safety Monitoring Updates:

  • Current echocardiogram with LVEF
  • Recent ophthalmologic examination
  • Laboratory monitoring results (CPK, liver function)
  • Documentation of any dose modifications and rationale

Continued Medical Necessity:

  • Statement that patient continues to benefit from therapy
  • Confirmation that no unacceptable toxicities have occurred
  • Plan for ongoing monitoring and treatment duration

Quick Reference Checklist

Before Submitting PA

  • Verify Aetna plan type and DMHC regulation status
  • Confirm Koselugo formulary coverage
  • Gather NF1 diagnostic documentation
  • Obtain recent imaging showing inoperable plexiform neurofibromas
  • Complete baseline safety evaluations (echo, eye exam, labs)
  • Calculate BSA-based dosing

Submission Packet

  • CVS Specialty enrollment form
  • Aetna CVS Health Koselugo PA form
  • Comprehensive medical necessity letter
  • All supporting clinical documentation
  • Surgical consultation confirming inoperability

After Submission

  • Track submission confirmation number
  • Follow up within 48 hours
  • Respond promptly to information requests
  • Prepare appeal materials if needed
  • Calendar renewal timeline

FAQ

How long does Aetna CVS Health prior authorization take for Koselugo in California? Standard PA decisions are typically made within 72 hours to 1 week, as required by California DMHC regulations. Expedited reviews for urgent cases must be decided within 24-72 hours.

What if Koselugo is not on Aetna's formulary? Koselugo is typically covered as a specialty drug requiring prior authorization. If listed as non-formulary, request a formulary exception with medical necessity documentation showing it's the only FDA-approved option for NF1 plexiform neurofibromas.

Does step therapy apply to Koselugo for NF1? Step therapy rarely applies because Koselugo is the only FDA-approved systemic therapy specifically for this indication. Plans cannot reasonably require failure of non-approved alternatives.

Can I request an expedited appeal if denied? Yes, if delay in treatment could seriously jeopardize your child's health or ability to regain maximum function. Include physician documentation of urgency in your appeal request.

What happens if CVS Specialty is not in my network? For most Aetna CVS Health plans, specialty drugs like Koselugo must be filled through CVS Specialty. Contact member services to confirm network requirements and any exceptions process.

How much does Koselugo cost with Aetna coverage? Costs vary by plan, but specialty drug copays typically range from $30-$100+ per month. Check with CVS Specialty about manufacturer copay assistance programs that may reduce out-of-pocket costs.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and is not medical advice. Always consult with your healthcare provider about treatment decisions. For specific questions about your Aetna coverage, contact member services directly. For assistance with California insurance regulations, contact the DMHC Help Center at 888-466-2219.

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