By Counterforce Health Team in Koselugo (selumetinib) —

How to Get Koselugo (Selumetinib) Covered by Aetna CVS Health in Illinois: Complete Guide with Forms and Appeals

Answer Box: Getting Koselugo Covered by Aetna CVS Health in Illinois

Quick Path to Approval: Koselugo (selumetinib) requires prior authorization from Aetna CVS Health for pediatric NF1 patients. Your fastest route: 1) Have your specialist complete the Illinois Uniform PA Form, 2) Submit with NF1 diagnosis proof and imaging showing symptomatic plexiform neurofibromas, 3) Enroll with CVS Specialty Pharmacy simultaneously. Standard decisions take 72 hours; expedited reviews within 24 hours for urgent cases. If denied, Illinois offers automatic external review for medical necessity denials.

Table of Contents

  1. Start Here: Verify Your Plan and Find Forms
  2. Required Forms and Documentation
  3. Submission Portals and Online Access
  4. Fax and Mail Options
  5. CVS Specialty Pharmacy Enrollment
  6. Support Phone Lines and Case Management
  7. Illinois Appeals and External Review
  8. Common Denial Reasons and Solutions
  9. Costs and Patient Assistance
  10. Frequently Asked Questions

Start Here: Verify Your Plan and Find Forms

Before requesting Koselugo coverage, confirm your specific Aetna plan type. Illinois residents may have:

  • Aetna Commercial Plans (employer-sponsored)
  • Aetna Better Health Illinois Medicaid
  • State of Illinois Employee Health Plan (administered by Aetna)

Each plan type uses different forms and processes. Check your member ID card or call the number on your card to verify your plan type.

Tip: Koselugo requires specialty pharmacy dispensing through CVS Specialty. Start both the PA process and specialty enrollment simultaneously to avoid delays.

Required Forms and Documentation

Primary Prior Authorization Form

Illinois uses the standardized Illinois Uniform Electronic Prior Authorization Form for prescription drug requests. This form must include:

Required Clinical Documentation:

  • Confirmed NF1 diagnosis with genetic testing or clinical criteria
  • Imaging (MRI) showing symptomatic, inoperable plexiform neurofibromas
  • Documentation of symptoms affecting function or quality of life
  • Baseline cardiac function (LVEF) assessment
  • Baseline ophthalmologic examination
  • Patient's weight and body surface area for dosing calculations

Medical Necessity Letter Template

Your specialist should include a letter addressing:

  1. Problem Statement: "Patient has confirmed NF1 with symptomatic plexiform neurofibromas causing [specific symptoms]"
  2. Clinical Rationale: Reference FDA approval for pediatric NF1-PN and clinical trial data
  3. Alternative Treatments: Explain why surgery is not feasible
  4. Monitoring Plan: Cardiac, ophthalmologic, and response monitoring schedule
  5. Guidelines: Cite FDA labeling and NF clinical guidelines

Coverage at a Glance

Requirement What It Means Where to Find It Timeline
Prior Authorization Required for all plans Illinois PA Form 72 hours standard
Age Restriction FDA approved ≥2 years FDA Label N/A
Specialty Pharmacy CVS Specialty required Enrollment Form 1-3 business days
Baseline Testing LVEF, eye exam required Aetna medical policy Before treatment

Submission Portals and Online Access

For Providers

Aetna Provider Portal (Availity):

  • Submit PA requests electronically
  • Track approval status
  • Access member benefits verification
  • Provider Portal Access (verify current link)

CVS Specialty Portal:

  • Enroll patients for specialty medications
  • Submit clinical documentation
  • Track shipment status

For Members

Aetna Member Portal:

  • View PA status
  • Access denial letters
  • Submit appeals online
  • Check formulary coverage

Fax and Mail Options

Prior Authorization Submissions

Standard PA Requests:

  • Fax: 1-800-294-5979 (non-specialty)
  • Fax: 1-866-814-5506 (specialty medications)
  • Include cover sheet with member ID and "URGENT" if expedited

CVS Specialty Enrollment:

  • Fax: 1-800-323-2445
  • Email: [email protected]
  • Mail: CVS Specialty Pharmacy, Customer Service, 9900 Corporate Campus Dr., Louisville, KY 40223
Note: Hand-written prescriber signatures required on all forms. Stamped signatures are not accepted.

CVS Specialty Pharmacy Enrollment

Koselugo must be dispensed through CVS Specialty Pharmacy. Start enrollment immediately after PA submission.

Step-by-Step Enrollment Process

  1. Download Form: Get the Oncology Orals Enrollment Form
  2. Complete Required Sections:
    • Patient demographics and insurance information
    • Prescriber details with NPI and DEA numbers
    • Clinical information including allergies and comorbidities
    • Prescription details with exact dosing
  3. Attach Documentation:
    • Front and back of insurance card
    • Clinical notes supporting diagnosis
    • Any relevant lab results
  4. Submit with Signature:
    • Prescriber must sign by hand (no stamps)
    • Fax to 1-800-323-2445 or submit online
  5. Follow Up:
    • Call 1-800-237-2767 for status updates
    • CVS will coordinate with Aetna on PA approval

Support Phone Lines and Case Management

Member Services by Plan Type

State of Illinois Employees (Aetna):

  • Phone: 1-855-339-9731 (TTY: 711)
  • Hours: Monday-Friday, 7 AM - 5 PM CT

Aetna Better Health Illinois Medicaid:

  • Phone: 1-866-329-4701 (TTY: 711)
  • Hours: Monday-Friday, 8:30 AM - 5:00 PM
  • 24-hour nurse line available

Commercial Plans:

  • Phone: Number on your member ID card
  • General Aetna: 1-800-872-3862 (TTY: 711)

Specialty Support

CVS Specialty Pharmacy:

  • Phone: 1-800-237-2767
  • Hours: Monday-Friday, 8 AM - 8 PM ET

Pharmacy Precertification:

  • Specialty drugs: 1-866-814-5506
  • Non-specialty: 1-800-294-5979

What to Ask When You Call

  • "What's the status of my Koselugo prior authorization?"
  • "What additional documentation do you need?"
  • "Can I request an expedited review?"
  • "What's my formulary tier for Koselugo?"
  • "Can I speak with case management about my NF1 treatment?"

Illinois Appeals and External Review

Illinois has strengthened patient appeal rights significantly in 2025, offering automatic external review for medical necessity denials.

Internal Appeals Process

Timeline: 60 days from denial date to file Contact: Use member portal or call member services Required: Medical necessity documentation and prescriber support

Automatic External Review (New 2025)

If your internal appeal is denied based on medical necessity, Illinois automatically forwards your case for external review unless you opt out. This process:

  • Cost: Free to patients
  • Timeline: 5 business days for decision
  • Reviewer: Board-certified specialist in relevant field
  • Decision: Binding on Aetna with up to $50,000 penalties for non-compliance

Expedited Appeals

For urgent situations where delays could jeopardize health:

  • Timeline: 24-72 hours for decision
  • How to Request: Call member services or contact Illinois DOI directly
  • Required: Physician statement of urgency

Illinois Department of Insurance Contact

External Review Requests:

Common Denial Reasons and Solutions

Denial Reason How to Overturn Required Documentation
"Not FDA approved for age" Provide birth certificate showing ≥2 years Birth certificate, current weight
"Experimental/Investigational" Submit FDA approval letter and label FDA Approval Letter
"Lack of medical necessity" Detailed symptom documentation and imaging MRI reports, functional assessments
"Missing baseline testing" Complete cardiac and eye exams ECHO/MUGA results, ophthalmology report
"Not specialty pharmacy" Transfer to CVS Specialty CVS enrollment confirmation

Scripts for Common Situations

When Calling About a Denial: "I'm calling about my child's Koselugo prior authorization denial. The denial reason was [specific reason]. I have additional clinical documentation from our NF specialist. Can you tell me exactly what you need for reconsideration and how to submit it?"

Requesting Peer-to-Peer Review: "Our NF specialist would like to request a peer-to-peer review with your medical director to discuss the clinical necessity of Koselugo for my child's symptomatic plexiform neurofibromas. How do we schedule this?"

Costs and Patient Assistance

AstraZeneca Support Programs

Koselugo Patient Access Program:

  • Copay assistance for commercially insured patients
  • Free drug program for uninsured/underinsured
  • Contact: Koselugo.com patient support (verify current link)

Illinois-Specific Resources

Illinois Comprehensive Health Insurance Plan:

  • High-risk pool for those denied coverage
  • May cover specialty medications with PA

Children's Tumor Foundation:

  • Grants for NF-related treatments
  • Patient advocacy support

When to Escalate

Contact Illinois regulators if:

  • Appeals are taking longer than legal timeframes
  • Aetna isn't following proper procedures
  • You need help understanding your rights

Illinois Department of Insurance Consumer Assistance:

  • Phone: 1-877-527-9431
  • Online complaint filing available

Illinois Attorney General Health Care Bureau:

  • Phone: 1-877-305-5145
  • Can intervene informally with insurers

Frequently Asked Questions

Q: How long does Aetna prior authorization take for Koselugo in Illinois? A: Standard PA decisions must be made within 72 hours under Illinois law. Expedited reviews for urgent cases are decided within 24 hours.

Q: What if Koselugo isn't on my formulary? A: You can request a formulary exception with medical necessity documentation. The appeals process applies to formulary exceptions.

Q: Can adults get Koselugo covered by Aetna? A: Koselugo is FDA-approved only for pediatric patients. Adults with NF1 may be directed to mirdametinib (Gomekli), approved in 2025 for adults and children.

Q: Does step therapy apply to Koselugo? A: As a first-line FDA-approved treatment for NF1 plexiform neurofibromas, step therapy typically doesn't apply, but confirm with your specific plan.

Q: What happens if my child turns 18 during treatment? A: Continuation of therapy is typically covered if treatment was established during pediatric years. Discuss transition planning with your care team.

Q: Can I appeal to someone outside Aetna? A: Yes, Illinois offers binding external review through independent physicians. This is automatic for medical necessity denials as of 2025.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed responses. The platform analyzes denial letters and payer policies to identify specific denial reasons and draft point-by-point rebuttals using the right clinical evidence and procedural requirements for each payer's workflow.

Sources and Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances and plan details. Always consult with your healthcare provider and insurance plan directly. For personalized assistance with insurance appeals, consider consulting with Counterforce Health or other qualified patient advocacy services.

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