By Counterforce Health Team in Krystexxa (pegloticase) —

How to Get Krystexxa (Pegloticase) Covered by Aetna CVS Health in Illinois: Prior Authorization, Appeals, and Cost Savings

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

To get Krystexxa (pegloticase) covered by Aetna CVS Health in Illinois, you must first document failure of both allopurinol and febuxostat for at least 3 months each at maximum tolerated doses. Submit a prior authorization through CVS Specialty with clinical records showing persistent gout symptoms and serum uric acid >6 mg/dL. If denied, you have 180 days to appeal and can pursue external review through Illinois' independent review process. First step: Contact your rheumatologist to gather documentation of prior treatment failures and current lab results.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required Must get approval before treatment Aetna Precertification List
Age Restriction Must be 18 years or older FDA labeling requirements
Step Therapy Failed allopurinol AND febuxostat (3+ months each) Aetna medical policy
Methotrexate Co-therapy Required unless contraindicated Updated FDA labeling
Specialty Pharmacy Only Dispensed through CVS Specialty CVS Specialty Drug List
Prescriber Requirement Rheumatologist or specialist preferred Payer medical policies
Lab Monitoring Serum uric acid >6 mg/dL documented Clinical documentation

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient + Clinic)

Collect records showing:

  • Diagnosis of chronic gout with frequent flares or tophi
  • Prior trials of allopurinol and febuxostat with doses, duration, and outcomes
  • Current serum uric acid levels >6 mg/dL
  • G6PD test results (required before starting Krystexxa)

2. Confirm Prescriber Credentials

Ensure your doctor is a rheumatologist or has experience with specialty gout treatments. Some Aetna policies prefer specialist prescribers.

3. Submit Prior Authorization (Clinic)

Your healthcare provider submits the PA request through:

  • CVS Specialty pharmacy portal
  • Aetna provider portal
  • Fax to designated prior authorization department

Timeline: Standard decisions within 15-30 days; expedited within 24-72 hours for urgent cases.

4. Plan for Methotrexate Co-therapy

Unless contraindicated, Aetna requires weekly methotrexate (typically 15 mg) with folic acid supplementation to improve Krystexxa effectiveness.

5. Coordinate Specialty Pharmacy

Once approved, CVS Specialty will contact you to:

  • Verify insurance coverage and copay
  • Schedule delivery to your infusion center
  • Provide injection training if applicable

6. Schedule Infusion Appointments

Krystexxa is given as an 8 mg IV infusion every 2 weeks at an outpatient infusion center or hospital.

7. Monitor and Document Response

Track serum uric acid levels before each infusion. If levels rise above 6 mg/dL, treatment may need to be discontinued.

Understanding Your Benefit Design

Specialty Tier Placement

Krystexxa is classified as a specialty medication, typically placed on the highest formulary tier with:

  • Higher coinsurance (often 25-40% of drug cost)
  • Separate specialty deductible
  • Annual out-of-pocket maximums that may differ from standard medical benefits

What Drives High Costs

The primary cost drivers for Krystexxa include:

  • Drug cost: Approximately $30,000 per 8 mg vial
  • Administration fees: Infusion center charges
  • Monitoring costs: Regular lab work and specialist visits
  • Annual treatment cost: Can exceed $700,000 for drug alone
Note: Illinois residents with ACA marketplace plans have annual out-of-pocket maximums that cap your total yearly costs, providing some protection against catastrophic expenses.

Investigating Your Coverage

Key Questions to Ask Aetna

When calling member services at the number on your insurance card:

  1. "Is Krystexxa covered under my pharmacy or medical benefit?"
  2. "What's my specialty drug copay or coinsurance?"
  3. "Do I have a separate specialty deductible?"
  4. "Which infusion centers are in-network for administration?"
  5. "Is CVS Specialty my required specialty pharmacy?"

Information to Record

  • Reference number for your call
  • Representative's name and ID
  • Specific copay amounts quoted
  • Prior authorization requirements confirmed
  • Any coverage limitations mentioned

Cost Assistance Options

Manufacturer Copay Program

Amgen Commercial Co-Pay Program can reduce your out-of-pocket costs to $0 per dose for eligible patients.

Eligibility Requirements:

  • Commercial (private) insurance that covers Krystexxa
  • NOT eligible if covered by Medicare, Medicaid, VA, or TRICARE
  • Must be prescribed for FDA-approved use
  • Cannot use with HSA/FSA funds for covered amounts

How to Apply: Contact Amgen By Your Side at 877-633-9521 or visit their program website.

Independent Foundation Assistance

For patients with government insurance or those who don't qualify for manufacturer programs:

  • Patient Access Network Foundation
  • HealthWell Foundation
  • Chronic Disease Fund
  • Good Days Foundation

Illinois-Specific Resources

  • Illinois Department of Insurance Consumer Assistance: 877-527-9431
  • Illinois Attorney General Health Care Helpline: 877-305-5145
From our advocates: "We've seen patients successfully combine manufacturer copay assistance with careful infusion center selection to reduce annual costs from over $50,000 to under $1,000. The key is applying for assistance programs before your first infusion and confirming all eligibility requirements upfront."

When Prior Authorization Gets Denied

Common Denial Reasons and Solutions

Denial Reason How to Overturn
"Step therapy not completed" Submit records showing allopurinol AND febuxostat trials with specific doses and durations
"Not medically necessary" Provide documentation of frequent gout flares, tophi, or joint damage
"Experimental/investigational" Reference FDA approval and current labeling
"Prescriber not qualified" Request peer-to-peer review or transfer care to rheumatologist
"Missing lab values" Submit recent serum uric acid levels and G6PD test results

Medical Necessity Documentation

Your rheumatologist should include:

  • Problem: Chronic gout refractory to standard therapy
  • Prior treatments: Specific medications tried, doses, duration, and reasons for failure
  • Clinical rationale: Frequency of flares, presence of tophi, impact on quality of life
  • Guideline support: Reference to ACR gout management guidelines
  • Monitoring plan: Serum uric acid tracking and safety monitoring

Appeals Process in Illinois

Internal Appeals with Aetna

Level 1 Appeal:

  • File within 180 days of denial
  • Decision within 15 days (pre-service) or 30 days (post-service)
  • Urgent appeals: Decision within 36 hours

Level 2 Appeal:

  • File within 60 days of Level 1 decision
  • Same timelines as Level 1
  • Must exhaust both levels before external review

External Review (Illinois)

If Aetna upholds the denial after internal appeals, Illinois residents can request an Independent Review Organization (IRO) review under the Illinois Health Carrier External Review Act.

Key Details:

  • Must request within 30 days of final internal appeal decision
  • IRO decision within 5 business days (standard) or 72 hours (expedited)
  • Decision is binding on Aetna
  • No cost to patient

How to Request: Contact the Illinois Department of Insurance at 877-527-9431 or use their online portal.

When to Expedite

Request expedited appeals if:

  • You're experiencing frequent, severe gout flares
  • Delay would seriously jeopardize your health
  • You're at risk of permanent joint damage

Specialty Pharmacy Coordination

CVS Specialty Process

As an Aetna member, you'll likely use CVS Specialty for Krystexxa:

  1. Enrollment: CVS Specialty contacts you after PA approval
  2. Benefits verification: They confirm your coverage and copay
  3. Delivery coordination: Medication shipped to your infusion center
  4. Refill management: Automatic coordination for ongoing doses

Tips for Smooth Coordination

  • Provide accurate contact information to both CVS Specialty and your infusion center
  • Confirm delivery timing to avoid delays in your treatment schedule
  • Keep CVS Specialty updated on any insurance changes
  • Ask about their patient support services and educational materials

Renewal and Budget Planning

Annual Considerations

  • Formulary changes: Krystexxa's tier placement may change each plan year
  • Prior authorization renewal: May need annual reauthorization
  • Deductible reset: Specialty deductibles restart each January
  • Copay program renewal: Manufacturer assistance typically requires annual re-enrollment

Planning Ahead

  • Review your plan's Summary of Benefits and Coverage each open enrollment
  • Consider switching to plans with better specialty drug coverage if available
  • Budget for potential changes in copay assistance program availability

Conversation Scripts

Calling Aetna Member Services

"Hi, I'm calling about prior authorization for Krystexxa, also called pegloticase, for chronic gout treatment. My member ID is [X]. Can you tell me the status of my prior authorization request submitted by Dr. [Name]? If it's been denied, I'd like to understand the specific reasons and how to appeal."

Requesting Peer-to-Peer Review

"This is [Clinic name] calling to request a peer-to-peer review for our patient's Krystexxa prior authorization denial. The patient has failed both allopurinol and febuxostat, and Dr. [Name] would like to discuss the medical necessity with your reviewing physician."

Pharmacy Benefits Question

"I need to understand my specialty drug coverage for Krystexxa. What's my coinsurance percentage, do I have a separate specialty deductible, and what's my annual out-of-pocket maximum for specialty medications?"

FAQ

How long does Aetna prior authorization take for Krystexxa in Illinois? Standard decisions are made within 15 days for pre-service requests. Expedited reviews for urgent cases are completed within 24-72 hours.

What if Krystexxa isn't on my formulary? You can request a formulary exception by providing documentation that covered alternatives have failed or are contraindicated. Your doctor will need to submit clinical justification.

Can I appeal if I haven't tried febuxostat? Step therapy requirements typically mandate trials of both allopurinol and febuxostat. However, you may be able to appeal if febuxostat is contraindicated or caused intolerable side effects.

Does my rheumatologist need special credentials? While not always required, many Aetna policies prefer prescribers with rheumatology expertise. Some may require the prescriber to be board-certified in rheumatology.

What happens if I lose Krystexxa response? If your serum uric acid rises above 6 mg/dL before infusions, treatment should typically be discontinued due to increased risk of infusion reactions. Your doctor may need to explore alternative treatments.

How do I get expedited review in Illinois? Contact Aetna to request an expedited appeal, providing documentation that delay would seriously jeopardize your health. Illinois law requires decisions within 36-72 hours for urgent cases.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate insurance denials by creating targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to identify the specific denial basis and drafts point-by-point rebuttals aligned to each payer's requirements, significantly improving approval rates for complex medications like Krystexxa.

Sources & Further Reading

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about treatment decisions and insurance coverage options. Coverage policies and requirements may vary by plan and change over time. For assistance with complex insurance appeals, consider consulting with organizations like Counterforce Health that specialize in prior authorization and appeals support.

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