By Counterforce Health Team in Photrexa (riboflavin ophthalmic solution) —

How to Get Photrexa (Riboflavin) Covered by Aetna CVS Health in Georgia: Complete PA Guide & Appeal Forms

Answer Box: Getting Photrexa Covered by Aetna CVS Health in Georgia

Fastest path to approval: Submit prior authorization through Aetna's Availity portal with documented progressive keratoconus (serial topography showing Kmax progression), corneal thickness ≥400 microns, and ophthalmologist consultation. If denied, you have 180 days to appeal internally, then 60 days to file external review with Georgia Department of Insurance. Start today by gathering your topography reports and calling Aetna member services at the number on your ID card to confirm your plan's specific requirements.

Table of Contents

  1. Start Here: Verify Your Plan & Find the Right Forms
  2. Prior Authorization Forms & Requirements
  3. Submission Portals & Online Tools
  4. Fax & Mail Options
  5. Medical Necessity Criteria
  6. Appeals Process in Georgia
  7. Support Lines & Case Management
  8. Georgia Department of Insurance External Review
  9. Common Denial Reasons & Solutions
  10. Cost Assistance Programs
  11. FAQ

Start Here: Verify Your Plan & Find the Right Forms

Before diving into paperwork, confirm your specific Aetna plan details. Not all Aetna plans have identical requirements, and some employer-sponsored plans may have different processes.

First steps:

  1. Call Aetna member services at the number on your ID card or 800-445-5299 for Georgia plans
  2. Ask specifically about:
    • Whether Photrexa requires prior authorization
    • If corneal cross-linking is covered under medical or pharmacy benefits
    • Your plan's formulary tier for riboflavin solutions
    • Any step therapy requirements
Tip: Have your member ID, diagnosis code (H18.601-H18.609 for keratoconus), and prescribing physician's information ready when you call.

Prior Authorization Forms & Requirements

Aetna CVS Health requires prior authorization for Photrexa (riboflavin ophthalmic solution) when used for corneal collagen cross-linking. The key is demonstrating progressive keratoconus with proper documentation.

Required Documentation Checklist

✅ Progressive keratoconus evidence: Serial corneal topography showing Kmax progression (minimum 2 readings, 3-6 months apart)
✅ Pachymetry readings: Confirming corneal thickness ≥400 microns
✅ Clinical notes: Ophthalmologist documentation of diagnosis and progression
✅ ICD-10 codes: H18.601-H18.609 (keratoconus, unspecified/specified eye)
✅ Prior treatment history: Documentation of previous therapies tried
✅ Completed PA form: Available through Aetna's provider portal

Medical Necessity Criteria

According to Aetna's clinical policy, epithelium-off photochemical collagen cross-linking using riboflavin and UVA light is considered medically necessary for:

  • Progressive keratoconus with documented worsening
  • Corneal ectasia following refractive surgery
  • Prescription from or consultation with an ophthalmologist
Important: Aetna's approval of Photrexa does not automatically approve the cross-linking procedure itself—these may require separate authorizations.

Submission Portals & Online Tools

Primary Submission Method: Availity Portal

Most providers use the Availity portal (availity.com) for electronic prior authorization submissions. This is Aetna's preferred method and typically processes faster than fax or mail.

Portal requirements:

  • Registered provider account
  • All supporting documentation uploaded as PDFs
  • Complete prior authorization form

Alternative Submission Methods

  • Fax: 1-888-267-3277 (verify current number with your plan)
  • EMR integration: Some electronic medical records systems connect directly to Aetna's PA system
  • Mail: Address provided on specific PA forms (varies by plan type)

Processing times:

  • Standard review: ~15 business days after complete submission
  • Expedited review: ≤72 hours for urgent cases
  • Incomplete submissions cause delays—double-check all requirements

Medical Necessity Criteria

What Aetna Looks For

Aetna considers corneal collagen cross-linking medically necessary when:

  1. Documented progression: Evidence of worsening keratoconus through:
    • Increasing Kmax values on topography
    • Worsening visual acuity
    • Increasing astigmatism
    • Corneal steepening
  2. Appropriate candidate:
    • Corneal thickness ≥400 microns
    • Clear cornea without significant scarring
    • Realistic treatment expectations
  3. FDA-approved system: Photrexa with iLink (KXL) system only

Clinician Corner: Medical Necessity Letter

Your ophthalmologist's letter should include:

  • Current diagnosis with ICD-10 codes
  • Progression documentation with specific measurements
  • Treatment rationale citing FDA labeling and clinical guidelines
  • Prior therapies attempted (glasses, contacts, other treatments)
  • Contraindications to alternative treatments
  • Expected outcomes and monitoring plan

Appeals Process in Georgia

If your initial prior authorization is denied, Georgia law provides multiple appeal levels with specific deadlines.

Internal Appeals with Aetna

Timeline: Must file within 180 days of denial notice
Decision timeframe: 30 days for standard, 72 hours for expedited
How to file: Through Availity portal, fax, or mail using Aetna's appeal form

External Review Through Georgia DOI

If Aetna's internal appeal is denied, you can request external review through the Georgia Department of Insurance.

Critical deadline: 60 days from Aetna's final denial letter
Cost: Free to consumers
Process: Independent physicians review your case
Decision: Binding on Aetna if approved

To file external review:

  1. Complete Georgia DOI external review form
  2. Attach all medical records and correspondence
  3. Submit to address provided on form
  4. Contact Georgia DOI Consumer Services at 1-800-656-2298 for assistance

Support Lines & Case Management

Aetna Contact Numbers

  • Member Services: Number on your ID card or 800-445-5299
  • Provider Services: 1-855-240-0535 (verify current number)
  • External Review Unit: 1-877-848-5855
  • Specialty Pharmacy: Available through CVS Caremark

What to Ask When You Call

For members:

  • "Does my plan cover Photrexa for keratoconus?"
  • "What's my copay for specialty ophthalmology drugs?"
  • "Can you check the status of my prior authorization?"

For providers:

  • "What documentation do you need for Photrexa PA?"
  • "Can we schedule a peer-to-peer review?"
  • "What's the fastest way to submit additional clinical information?"

Georgia Department of Insurance External Review

When Aetna denies coverage after internal appeals, Georgia's external review process gives you an independent second opinion.

How Georgia's Process Works

  1. Eligibility check: Must have exhausted Aetna's internal appeals
  2. File within 60 days: Strict deadline from final denial letter
  3. Independent review: Georgia DOI assigns qualified reviewers
  4. Binding decision: Aetna must comply with favorable decisions

Required Documents

  • Completed external review request form
  • Copy of Aetna's final denial letter
  • All medical records supporting medical necessity
  • Any additional evidence not previously submitted

Georgia DOI Resources:

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
"Not medically necessary" Provide progression evidence Serial topography, Kmax values, clinical notes
"Experimental/investigational" Cite FDA approval FDA labeling, Aetna policy bulletin
"Non-formulary" Request formulary exception Medical necessity letter, alternative failures
Missing progression Submit historical data Prior topographies, visual acuity changes
Wrong provider type Get ophthalmologist referral Specialist consultation notes

Cost Assistance Programs

Manufacturer Support

Glaukos Patient Support Program:

  • Copay assistance for eligible patients
  • Prior authorization support
  • Reimbursement guidance for providers

Additional Resources

  • Patient Advocate Foundation: Copay relief programs
  • NeedyMeds: Database of patient assistance programs
  • Georgia 211: Local assistance program directory
Note: Assistance program eligibility varies by insurance type and income level.

FAQ

Q: How long does Aetna's prior authorization take in Georgia?
A: Standard review takes about 15 business days. Expedited reviews for urgent cases are completed within 72 hours.

Q: What if Photrexa is non-formulary on my plan?
A: Request a formulary exception with medical necessity documentation. Your doctor must show why covered alternatives won't work.

Q: Can I get an expedited appeal if my vision is worsening quickly?
A: Yes. Your ophthalmologist can request expedited review by documenting urgent medical necessity.

Q: Does step therapy apply to Photrexa in Georgia?
A: Aetna may require trying other keratoconus treatments first. Document failures or contraindications to covered alternatives.

Q: What happens if I miss the 60-day external review deadline?
A: You lose the right to external review. Always file within 60 days of Aetna's final denial letter.

Q: Is the cross-linking procedure covered separately from Photrexa?
A: Often yes. The drug and procedure may require separate prior authorizations under different benefit categories.

When You Need Extra Help

Getting specialty treatments approved can be complex, especially when dealing with prior authorizations and appeals. Counterforce Health helps patients, clinicians, and specialty pharmacies 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 each payer's specific requirements.

If you're facing repeated denials or complex appeals, consider working with advocates who understand Aetna's specific processes and Georgia's regulatory environment. The right support can make the difference between a denied claim and approved coverage for the treatment you need.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance company for specific guidance. For assistance with insurance appeals and coverage issues in Georgia, contact the Georgia Department of Insurance Consumer Services Division or consult with qualified patient advocates.

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