By Counterforce Health Team in Krystexxa (pegloticase) —

How to Get Krystexxa (Pegloticase) Covered by Aetna (CVS Health) in Georgia: Complete Prior Authorization Guide

Answer Box: Getting Krystexxa (Pegloticase) Covered by Aetna (CVS Health) in Georgia

Krystexxa requires prior authorization from Aetna (CVS Health) in Georgia. You must document failure of conventional gout therapies (allopurinol, febuxostat) for at least 3 months, have persistent serum uric acid ≥6 mg/dL, and get a prescription from a rheumatologist. First step today: Call the member services number on your Aetna ID card to verify your specialty drug benefits and request the current prior authorization form. If denied, you have 180 days for internal appeal and 60 days after that for external review through the Georgia Department of Insurance.

Table of Contents

  1. Start Here: Verify Your Plan and Find Forms
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Methods
  4. Fax Numbers and Mailing Addresses
  5. CVS Specialty Pharmacy Enrollment
  6. Member and Provider Support Lines
  7. Appeals Process in Georgia
  8. Common Denial Reasons and Solutions
  9. Cost-Saving Resources
  10. FAQ

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Aetna plans Member portal or ID card number Aetna Policy
Step Therapy Must fail allopurinol + febuxostat Medical records, 3+ months each Coverage Criteria
Prescriber Rheumatologist required Provider credentials Medical Policy
Age Requirement 18+ years old Patient demographics Coverage Criteria
G6PD Testing Must test negative Lab results FDA Label
Appeals Deadline 180 days internal, 60 days external Denial notice Georgia DOI

Start Here: Verify Your Plan and Find Forms

Before starting your prior authorization request, you need to confirm your specific Aetna plan details and coverage requirements.

Step 1: Call Member Services Call the number on your Aetna ID card to:

  • Verify your specialty drug benefits
  • Confirm if Krystexxa is on your formulary
  • Request the current prior authorization form
  • Ask about any plan-specific requirements

Step 2: Identify Your Coverage Type Aetna (CVS Health) processes Krystexxa differently based on your plan:

  • Commercial plans: Standard PA through CVS Caremark
  • Medicare Advantage: Additional CMS requirements may apply
  • Medicaid: State-specific criteria in Georgia
Tip: Write down your member ID, group number, and the representative's name when you call. This information will be essential for all future communications.

Prior Authorization Forms and Requirements

Required Documentation Checklist

Clinical Requirements:

  • Diagnosis of chronic gout with ICD-10 codes
  • Documented failure of allopurinol (3+ months, up to 800mg/day or maximum tolerated)
  • Documented failure of febuxostat (3+ months at appropriate doses)
  • Serum uric acid levels ≥6 mg/dL despite conventional therapy
  • G6PD deficiency test results (must be negative)
  • At least 2 gout flares per year OR non-resolving subcutaneous tophi

Prescriber Requirements:

  • Must be a rheumatologist or have rheumatology consultation
  • Detailed clinical notes supporting medical necessity
  • Treatment plan including monitoring protocols

Medical Necessity Letter Template

Your rheumatologist should include these elements in the medical necessity letter:

  1. Patient background: Age, diagnosis, duration of gout
  2. Prior treatments: Specific medications, doses, duration, reasons for failure
  3. Current status: Serum uric acid levels, frequency of flares, presence of tophi
  4. Clinical rationale: Why Krystexxa is medically necessary
  5. Monitoring plan: How treatment response will be assessed
Clinician Corner: According to Aetna's medical policy, the medical necessity letter must demonstrate "refractory chronic gout" with specific documentation of inadequate response to conventional therapy. Include exact dates, doses, and clinical outcomes for each prior treatment.

Submission Portals and Methods

Electronic Submission

  • Aetna Provider Portal: Log in through your existing provider account
  • CVS Caremark Portal: For specialty pharmacy coordination
  • Upload all supporting documents as PDFs
  • Ensure file sizes are under portal limits

Required Attachments

  • Completed prior authorization form
  • Medical necessity letter from rheumatologist
  • Lab results (serum uric acid, G6PD testing)
  • Clinical notes documenting prior treatment failures
  • Prescription with NDC/J-code information

Fax Numbers and Mailing Addresses

CVS Caremark Specialty Pharmacy

  • Primary Fax: 1-866-237-5512
  • Use this number for Krystexxa enrollment and prior authorization submissions
  • Include cover sheet with patient name, member ID, and provider information

Amgen By Your Side Patient Support

Note: Always maintain HIPAA compliance when faxing protected health information. Verify fax numbers before transmission and use cover sheets indicating confidential medical information.

CVS Specialty Pharmacy Enrollment

Once prior authorization is approved, patients must enroll with CVS Specialty Pharmacy for Krystexxa fulfillment.

Enrollment Process

  1. Provider submits enrollment form to CVS Caremark (fax: 1-866-237-5512)
  2. CVS contacts patient to coordinate delivery and infusion site
  3. Patient provides insurance information and delivery preferences
  4. CVS coordinates with infusion center for administration

Required Information

  • Insurance card and member ID
  • Prescriber information and NPI number
  • Preferred infusion site details
  • Emergency contact information

Counterforce Health helps streamline this process by automatically generating the required enrollment forms with all necessary clinical documentation, reducing delays and improving approval rates.

Member and Provider Support Lines

Aetna Member Services

  • General: Number on your ID card (plan-specific)
  • General Line: 1-888-792-3862 (TTY: 711)
  • Hours: Monday-Friday 7 AM-11 PM ET, Saturday 7 AM-9:30 PM ET, Sunday 8 AM-6 PM ET

Case Management

  • Access through member portal or by calling your ID card number
  • Request connection to specialty drug case management
  • Ask for a dedicated nurse case manager for complex conditions

Provider Support

  • CVS Caremark: 1-808-254-4414
  • Amgen By Your Side: Support for enrollment and insurance navigation

Appeals Process in Georgia

If your initial prior authorization is denied, Georgia law provides multiple levels of appeal.

Level 1: Internal Appeal with Aetna

  • Deadline: 180 days from denial notice
  • Timeline: Standard review within 30-45 days, expedited within 72 hours
  • Submission: Use address/fax on your denial letter
  • Required: All original documentation plus any new supporting evidence

Level 2: External Review through Georgia DOI

  • Deadline: 60 days from final internal appeal decision
  • Process: Independent review by Georgia Department of Insurance
  • Cost: Free to consumers
  • Timeline: 30 business days (72 hours for urgent cases)

How to File External Review

  1. Contact Georgia DOI: [email protected]
  2. Complete form: Use official external review application
  3. Submit documents: Include all appeal correspondence and medical records
  4. Wait for decision: DOI assigns independent review organization
Important: The 60-day deadline for external review in Georgia is strict. Begin preparing your external review application as soon as you receive an internal appeal denial.

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Inadequate step therapy Document 3+ months each of allopurinol and febuxostat Pharmacy records, clinical notes with dates/doses
Missing G6PD test Order and submit negative G6PD test results Lab report within 30 days
Non-rheumatology prescriber Get rheumatology consultation or referral Consultation notes, specialist prescription
Insufficient serum uric acid Provide multiple SUA readings ≥6 mg/dL Lab results over time showing persistent elevation
Experimental/investigational Cite FDA approval and medical guidelines FDA label, clinical guidelines, peer-reviewed studies

Appeal Strategy

When appealing a denial, Counterforce Health recommends addressing each specific denial reason with point-by-point rebuttals using Aetna's own policy language and supporting clinical evidence.

Cost-Saving Resources

Manufacturer Support Programs

  • Amgen By Your Side: Financial assistance and copay support
  • Eligibility: Based on income and insurance type
  • Application: Through provider or patient enrollment

Foundation Grants

  • Patient Access Network Foundation: Gout-specific assistance
  • HealthWell Foundation: Chronic disease support
  • National Organization for Rare Disorders: Emergency assistance

Georgia-Specific Resources

  • Georgians for a Healthy Future: Consumer assistance with appeals
  • Georgia Legal Services: Free legal help for complex cases
  • 211 Georgia: Connect to local assistance programs

FAQ

How long does Aetna prior authorization take in Georgia? Standard prior authorization decisions are typically made within 5-10 business days. Expedited requests (for urgent medical needs) must be processed within 72 hours per federal regulations.

What if Krystexxa is non-formulary on my Aetna plan? You can request a formulary exception by demonstrating medical necessity and failure of formulary alternatives. The process is similar to prior authorization but may require additional clinical justification.

Can I get an expedited appeal if my condition is urgent? Yes, if your physician certifies that waiting for standard review timelines could seriously jeopardize your health, you can request expedited review at both internal and external levels.

Does step therapy apply if I failed these drugs in another state? Yes, documented treatment failures from other states count toward step therapy requirements. Ensure you have complete medical records from previous providers.

What happens if both internal and external appeals are denied? After exhausting administrative appeals, you may have legal options. Consider consulting with a healthcare attorney or patient advocacy organization for guidance.

How much does Krystexxa cost without insurance? The average wholesale price is approximately $30,000 per 8mg vial, with patients typically receiving infusions every two weeks. Annual costs can exceed $780,000 for drug costs alone.

From Our Advocates

"We've seen many Krystexxa approvals succeed when providers include a detailed timeline of prior treatments with specific dates, doses, and clinical outcomes. One case that stood out involved a patient whose initial denial was overturned simply by adding pharmacy records showing exact allopurinol dosing progression over six months. The key is comprehensive documentation that leaves no room for interpretation."

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice and should not replace consultation with your healthcare provider or insurance representative. Coverage policies and requirements may change. Always verify current information with your insurer and healthcare team. For personalized assistance with prior authorizations and appeals, consider consulting with a patient advocacy service or healthcare coverage specialist.

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