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

How to Get Photrexa (Riboflavin) Covered by Aetna CVS Health in New York: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Photrexa Covered by Aetna CVS Health in New York

Yes, Aetna CVS Health covers Photrexa (riboflavin ophthalmic solution) for progressive keratoconus with prior authorization. To get approved in New York: (1) Your cornea specialist submits prior authorization with serial topography showing progression, (2) Aetna typically decides within 24-48 hours for 95% of requests, and (3) If denied, you have strong appeal rights through New York's external review process. Start today: Contact your ophthalmologist to gather progression documentation and submit the PA request at least two weeks before your planned procedure.

Table of Contents

Is Photrexa Covered by Aetna CVS Health?

Aetna CVS Health requires prior authorization for Photrexa (riboflavin ophthalmic solution) when used with the iLink® corneal cross-linking system for progressive keratoconus. The treatment is covered when it meets medical necessity criteria and uses FDA-approved protocols.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required before treatment Aetna Precertification List
Progressive Keratoconus Documented worsening over time Serial corneal topography
FDA-Approved System iLink® system only Photrexa FDA Label
Minimum Corneal Thickness 400 microns via pachymetry Clinical examination
Step Therapy Not typically required Aetna policy

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Schedule Comprehensive Eye Exam (Patient)
    • Your ophthalmologist documents current keratoconus status
    • Timeline: Schedule ASAP
    • Required: Complete eye exam with topography
  2. Gather Serial Topography (Clinic)
    • Document progression over 3-6 months minimum
    • Timeline: May require waiting if recent diagnosis
    • Submit via: Availity® provider portal or Novologix®
  3. Submit Prior Authorization (Clinic)
    • Complete PA request with all documentation
    • Timeline: Submit at least 2 weeks before procedure
    • Portal: Aetna Provider Portal
  4. Aetna Review Process (Insurance)
    • Standard review of submitted documentation
    • Timeline: 95% approved within 24 hours
    • Expedited: Available for urgent cases
  5. Receive Approval (Patient/Clinic)
    • Authorization number provided
    • Timeline: Valid for specific time period
    • Next step: Schedule procedure
  6. Coordinate Specialty Pharmacy (Patient/Clinic)
    • Photrexa shipped to treatment facility
    • Timeline: 2-3 days before procedure
    • Partner: Often through Orsini Specialty Pharmacy
  7. Undergo Treatment (Patient)
    • Procedure performed at approved facility
    • Timeline: As scheduled
    • Follow-up: Post-treatment monitoring

Required Documentation

Medical Necessity Letter Checklist

Your cornea specialist must include:

  • Confirmed diagnosis of progressive keratoconus (ICD-10: H18.601-H18.609)
  • Serial corneal topography showing increased curvature over time
  • Pachymetry results confirming minimum 400-micron corneal thickness
  • Visual acuity measurements and refractive history
  • Prior treatment attempts with contact lenses or conservative measures
  • Treatment plan using FDA-approved iLink® system with Photrexa
Clinician Corner: The medical necessity letter should emphasize progressive nature of the condition. Include specific Kmax values from serial topographies, document contact lens intolerance or failure, and reference FDA approval of epithelium-off cross-linking for progressive keratoconus.

Timeline and Approval Process

Standard Timeline:

  • Prior authorization submission: 2 weeks before procedure
  • Aetna decision: 24-48 hours for most requests
  • Specialty pharmacy coordination: 2-3 days for drug delivery
  • Total process: 2-3 weeks from start to procedure

Expedited Process:

  • Available when delay would jeopardize health
  • Decision timeline: Within 72 hours
  • Required: Physician attestation of urgency

Counterforce Health helps patients and providers navigate complex prior authorization requirements by analyzing denial letters and crafting evidence-backed appeals that align with payer-specific criteria.

Coverage Criteria and Requirements

Medical Necessity Standards

Aetna covers Photrexa when:

  1. Progressive keratoconus is documented through serial measurements
  2. FDA-approved protocol using iLink® system is followed
  3. Conservative treatments have been attempted or are contraindicated
  4. Adequate corneal thickness (≥400 microns) is confirmed
  5. Appropriate candidate based on age and corneal condition

Step Therapy Requirements

Unlike many specialty medications, step therapy is not typically required for corneal cross-linking when FDA-approved systems are used for progressive keratoconus. However, documentation of prior contact lens trials or failures strengthens the medical necessity case.

Costs and Financial Assistance

Expected Costs

  • With Aetna coverage: Typically 20-33% coinsurance (specialty tier)
  • Without coverage: $2,500-$4,000 per eye
  • Deductible applies: Must be met before coinsurance kicks in

Financial Assistance Options

  • Manufacturer support: Check with Glaukos Corporation for patient assistance programs
  • FSA/HSA: Use pre-tax dollars for out-of-pocket costs
  • Payment plans: Many facilities offer financing options

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
Insufficient progression documentation Submit serial topography with clear Kmax increases
Missing pachymetry Provide corneal thickness measurements ≥400 microns
Non-FDA approved system Confirm iLink® system use in documentation
Lack of medical necessity Strengthen letter with contact lens failure/intolerance
Incomplete prior authorization Resubmit with all required clinical documentation

New York Appeals Process

If Aetna denies your Photrexa prior authorization, New York offers strong patient protections through its external appeal process.

Internal Appeal Process

  1. File internal appeal with Aetna CVS Health first
  2. Timeline: Must file within 60 days of denial
  3. Decision: Aetna has 30-45 days to respond
  4. Required: All supporting documentation and physician letter

New York External Appeal

If the internal appeal is denied, you can request an external review through the New York State Department of Financial Services (DFS).

Key Benefits:

  • Independent medical review by qualified specialists
  • Binding decision on Aetna CVS Health
  • Strong success rate for medically necessary treatments

Timeline:

  • 4 months to file after final internal denial
  • 30 days for standard external review decision
  • 72 hours for expedited appeals (urgent cases)
  • 24 hours for non-formulary drug expedited appeals

How to File:

  • Online: New York DFS External Appeal Portal
  • Phone: 1-800-400-8882
  • Fax: (800) 332-2729 (call 888-990-3991 for expedited appeals)
  • Mail: NY Department of Financial Services, 99 Washington Avenue, Box 177, Albany NY 12210

Required Documents:

  • Aetna's final internal appeal denial letter
  • Completed New York State External Appeal Application
  • Physician attestation form
  • All supporting medical records and literature

Cost: Up to $25 filing fee (waived for financial hardship, refunded if you win)

Free Help Available

Community Health Advocates provides free assistance to all New York residents with insurance appeals:

  • Phone: 888-614-5400
  • Services: Help filing appeals, understanding rights, gathering documentation
  • Cost: Completely free

Specialty Pharmacy Coordination

Once your prior authorization is approved, Photrexa will be dispensed through a specialty pharmacy network.

Distribution Process

  1. Prescription sent to designated specialty pharmacy
  2. Patient contact for delivery coordination
  3. Facility delivery 2-3 days before procedure
  4. Temperature control maintained during shipping

Key Partner: Orsini Specialty Pharmacy is an official distribution partner for Photrexa and works with many insurance plans including Aetna.

From our advocates: "We've seen patients successfully coordinate Photrexa delivery by confirming the treatment facility address with both their doctor and the specialty pharmacy. Having a backup contact number for the day of delivery prevents last-minute delays that could postpone the procedure."

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take for Photrexa? Most Photrexa prior authorizations are approved within 24-48 hours when complete documentation is submitted. Aetna approves over 95% of eligible requests quickly.

What if Photrexa is not on my Aetna formulary? You can request a formulary exception by having your doctor submit documentation that formulary alternatives are ineffective or inappropriate for your progressive keratoconus.

Can I request an expedited appeal in New York? Yes, if your doctor attests that a delay would seriously jeopardize your health, you can request expedited review with decisions in 24-72 hours depending on the type of appeal.

Does step therapy apply if I haven't tried contact lenses? Step therapy is not typically required for corneal cross-linking, but documenting contact lens trials or contraindications strengthens your medical necessity case.

What happens if I move from another state to New York? Your Aetna coverage terms remain the same, but you gain access to New York's robust external appeal protections if you face denials.

How do I find an in-network ophthalmologist for iLink treatment? Use Aetna's provider directory or search platforms like Zocdoc for "Aetna ophthalmologists New York" to find cornea specialists who perform cross-linking procedures.

What if my procedure is denied as experimental? The iLink® system with Photrexa is FDA-approved for progressive keratoconus. If denied as experimental, appeal with FDA approval documentation and established medical literature.

Can I use HSA/FSA funds for out-of-pocket costs? Yes, corneal cross-linking for progressive keratoconus qualifies as a medical expense eligible for HSA/FSA reimbursement.

When to Get Additional Help

Contact these resources if you need assistance:

  • Aetna CVS Health Member Services: Use the number on your insurance card
  • Community Health Advocates: 888-614-5400 (free help for NY residents)
  • NY Department of Financial Services: 1-800-400-8882 (external appeals)
  • Counterforce Health: Specialized assistance with prior authorization denials and appeals

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and appeal processes may vary by specific plan and can change. Always verify current requirements with your insurance provider and consult with qualified healthcare professionals for medical decisions.

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