By Counterforce Health Team in Krystexxa (pegloticase) —

How to Get Krystexxa (Pegloticase) Covered by Aetna CVS Health in Ohio: Complete Prior Authorization Guide (2025)

Answer Box: Getting Krystexxa Approved by Aetna CVS Health in Ohio

Fastest path to approval: Submit prior authorization with complete documentation showing failure of both allopurinol and febuxostat, normal G6PD test results, and rheumatologist prescription. Aetna typically decides within 72 hours of receiving complete documentation. If denied, you have 180 days to appeal and can request external review through Ohio's Independent Review Organization system.

Start today: Contact your rheumatologist to order G6PD testing and gather records of prior gout therapy failures—these are the most common missing pieces that delay approval.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Common Denial Reasons & How to Fix Them
  4. Appeals Process for Aetna CVS Health in Ohio
  5. Timeline Expectations
  6. Renewal Requirements
  7. Cost-Saving Options
  8. Frequently Asked Questions

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required Must get approval before treatment Aetna Precertification List
G6PD Testing Normal G6PD enzyme levels required Lab results from your physician
XOI Failure Documentation Failed both allopurinol AND febuxostat Clinical notes, prescription records
Rheumatologist Prescription Prescribed by or in consultation with rheumatologist Physician credentials, referral notes
HCPCS Code J2507 (8 units per 8mg dose) Krystexxa Billing Guide
Methotrexate Co-therapy Weekly MTX unless contraindicated Treatment plan documentation

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Benefits (1 day)

Who does it: You or your clinic
Document needed: Insurance card, member ID
How to submit: Call member services or check Aetna member portal
Timeline: Same day

Contact Aetna member services at the number on your insurance card to confirm Krystexxa requires prior authorization under your specific plan.

2. Order G6PD Testing (2-5 days)

Who does it: Your rheumatologist
Document needed: Lab order for G6PD enzyme activity
Timeline: 2-3 days for results

Critical: G6PD deficiency is an absolute contraindication for Krystexxa due to risk of severe hemolysis. This test must show normal results before approval.

3. Gather Prior Therapy Documentation (1-3 days)

Who does it: Clinic staff
Documents needed:

  • Prescription records for allopurinol (with maximum tolerated dose)
  • Prescription records for febuxostat (with maximum tolerated dose)
  • Clinical notes documenting inadequate response or intolerance
  • Recent serum uric acid levels (≥6 mg/dL despite therapy)

4. Complete Prior Authorization Form (1 day)

Who does it: Your rheumatologist's office
Document needed: Aetna Medical Prior Authorization Form
How to submit: Aetna provider portal or fax

The form must include:

  • ICD-10 diagnosis code for chronic gout (M1A.___)
  • HCPCS code J2507 with 8 units per dose
  • Planned methotrexate co-therapy (unless contraindicated)
  • Clinical justification for medical necessity

5. Submit Complete Package (Same day)

Timeline: Within 24 hours of completion
Required attachments:

  • Completed PA form with physician signature
  • G6PD test results (normal)
  • Clinical notes documenting gout severity and prior treatment failures
  • Recent lab results (serum uric acid levels)
  • Treatment plan including methotrexate co-therapy

6. Track Your Request (1-3 days)

Timeline: Aetna decides within 72 hours of receiving complete documentation
How to check: Provider portal or member services phone line

7. Respond to Information Requests Immediately (Same day)

If Aetna requests additional information, respond within 24 hours to avoid delays. Common requests include clarification of prior therapy duration or additional clinical notes.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
Missing G6PD test Submit normal G6PD enzyme activity results
Inadequate XOI trial Provide documentation of ≥3 months each of allopurinol AND febuxostat at maximum tolerated doses
Not prescribed by rheumatologist Obtain rheumatology consultation or referral documentation
Missing methotrexate plan Include weekly MTX dosing plan or document contraindications
Insufficient gout severity Submit records showing ≥2 flares/year or persistent tophi despite therapy
Coding errors Verify J2507 with 8 units per dose, include appropriate modifiers (JW/JZ for wastage)

Appeals Process for Aetna CVS Health in Ohio

Internal Appeal (First Level)

  • Timeline: 180 days from denial notice to file
  • Decision time: 45-60 business days (standard) or 36-72 hours (expedited)
  • How to file: Aetna Provider Resolution Team, PO Box 14020, Lexington, KY 40512
  • Required documents: Original denial letter, completed appeal form, additional medical evidence

External Review (Independent Review Organization)

If your internal appeal is denied, Ohio law provides access to external review through an Independent Review Organization (IRO).

  • Timeline: 180 days from final internal denial to request external review
  • Decision time: 30 days (standard) or 72 hours (expedited)
  • How to request: File with your health plan, which notifies the Ohio Department of Insurance
  • Cost: No cost to you
  • Binding decision: IRO decision is binding on Aetna
Ohio Advantage: Even if Aetna initially claims your case isn't eligible for external review, the Ohio Department of Insurance can independently determine eligibility and order a review.

For assistance with Ohio external reviews, contact the Ohio Department of Insurance Consumer Services Division at 1-800-686-1526.

Timeline Expectations

Milestone Standard Timeline Expedited Timeline
Complete documentation gathering 3-7 days 1-2 days
Initial PA decision 72 hours 24-48 hours
Appeal filing deadline 180 days Same
Internal appeal decision 45-60 business days 36-72 hours
External review decision 30 days 72 hours
Time-Saving Tip: Use Aetna's provider portal for faster submission and real-time status tracking rather than fax or mail.

Renewal Requirements

Krystexxa typically receives 6-month initial approvals with annual renewals thereafter. For reauthorization, you'll need:

  • Serum uric acid monitoring: Levels must remain ≤6 mg/dL during therapy
  • Clinical response documentation: Evidence of reduced gout flares or tophus improvement
  • Continued methotrexate therapy: Unless contraindicated
  • Adherence records: Documentation of consistent infusion schedule (every 2 weeks)
Important: If serum uric acid rises ≥6 mg/dL on two consecutive measurements, discontinuation is typically required due to increased infusion reaction risk.

Start your renewal process 2-4 weeks before your current authorization expires to avoid treatment gaps.

Cost-Saving Options

With drug costs exceeding $30,000 per infusion, financial assistance is crucial:

  • Amgen By Your Side: Patient support program offering copay assistance and case management. Visit AmgenByYourSide.com or call 1-833-AMG-4YOU
  • Foundation grants: Patient advocate organizations may offer assistance for qualifying patients
  • CVS Specialty Pharmacy: May offer payment plans or additional support programs

Clinician Corner: Medical Necessity Letter Checklist

When drafting your medical necessity letter, include:

✓ Clear diagnosis: Chronic gout refractory to conventional therapy (ICD-10: M1A.___)
✓ Prior treatment failures: Specific documentation of allopurinol and febuxostat trials with doses, duration, and outcomes
✓ Clinical severity: Frequency of flares (≥2/year) or presence of tophi
✓ Safety screening: Normal G6PD test results
✓ Treatment plan: Planned methotrexate co-therapy and monitoring schedule
✓ Guideline support: Reference to 2020 ACR Gout Management Guidelines and FDA labeling

From Our Advocates: We've seen denials overturned when physicians included specific details about why alternative urate-lowering therapies failed—not just "patient didn't respond," but "allopurinol 300mg daily for 4 months resulted in persistent SUA >8 mg/dL with 3 documented flares." Specificity matters in appeals.

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take in Ohio?
Standard decisions are made within 72 hours of receiving complete documentation. Expedited requests for urgent situations are processed within 24-48 hours.

What if Krystexxa is non-formulary on my plan?
You can request a formulary exception with medical necessity documentation. The appeal process is the same as for prior authorization denials.

Can I request an expedited appeal?
Yes, if a delay would seriously jeopardize your health. Contact Aetna member services to request expedited processing with supporting clinical documentation.

Does step therapy apply if I tried medications outside Ohio?
Yes, documented trials of allopurinol and febuxostat from any location count toward step therapy requirements, as long as you have medical records proving the attempts and outcomes.

What happens if my rheumatologist leaves the practice?
Your authorization remains valid through its expiration date. For renewals, the new rheumatologist can continue care by reviewing your medical history and submitting updated documentation.

How do I know if my G6PD test is normal?
Your lab results should show G6PD enzyme activity within the normal reference range. G6PD deficiency disqualifies you from Krystexxa therapy due to severe hemolysis risk.

When to Escalate

Contact the Ohio Department of Insurance at 1-800-686-1526 if:

  • Aetna fails to meet decision timelines
  • You're incorrectly told external review isn't available
  • You need help navigating the appeals process
  • You believe Aetna violated Ohio insurance regulations

For complex cases requiring specialized support, Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with payer requirements.

Sources & Further Reading

Medical Disclaimer: This information is for educational purposes only and is not medical advice. Always consult with your healthcare provider about your specific medical condition and treatment options. Insurance coverage decisions are made by your health plan based on your individual policy terms and medical circumstances. For personalized assistance with insurance appeals and prior authorizations, consider consulting with Counterforce Health, which specializes in helping patients navigate complex coverage challenges for specialty medications.

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