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

How to Get Photrexa (Riboflavin) Covered by Aetna CVS Health in Pennsylvania: Prior Authorization Guide

Quick Answer: Getting Photrexa Covered by Aetna CVS Health in Pennsylvania

Aetna CVS Health requires prior authorization for Photrexa (riboflavin ophthalmic solution) used in FDA-approved corneal cross-linking for progressive keratoconus in Pennsylvania. Your fastest path to approval: (1) Gather documented progression evidence (serial topography showing Kmax increases, pachymetry showing thinning), (2) Submit via Aetna's provider portal with complete clinical notes, and (3) Ensure your facility uses the FDA-approved iLink system. If denied, you have 180 days to appeal internally, then 4 months for Pennsylvania's state external review, which overturns ~50% of denials.

Start today: Contact your ophthalmologist to confirm they have progression documentation and are in Aetna's network.

Table of Contents

What This Guide Covers

This guide helps patients with progressive keratoconus and their doctors navigate Aetna CVS Health's prior authorization process for Photrexa (riboflavin ophthalmic solution) in Pennsylvania. Photrexa is the only FDA-approved photoenhancer for corneal collagen cross-linking, used with the iLink (KXL) system to slow or stop keratoconus progression.

Who this helps: Patients diagnosed with progressive keratoconus whose doctors recommend FDA-approved corneal cross-linking, and the clinicians who treat them.

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters and creating evidence-backed rebuttals aligned to each plan's specific requirements. Their platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization processes with targeted documentation and appeal strategies.

Before You Start: Verify Your Coverage

Check Your Plan Type

  • Commercial Aetna plans: Most cover FDA-approved corneal cross-linking
  • Aetna Medicare Advantage: May have additional requirements
  • Medicaid managed by Aetna: Coverage varies by state contract

Confirm Network Status

Call Aetna member services at the number on your insurance card to verify:

  • Your ophthalmologist is in-network
  • The surgical facility is in-network for the procedure
  • Whether Photrexa requires prior authorization under your specific plan

Medical vs. Pharmacy Benefit

Photrexa is typically covered under the medical benefit (not pharmacy) since it's administered during a surgical procedure. This means your medical deductible and copay apply, not prescription drug costs.

Gather What You Need

Required Clinical Documentation

Progressive Keratoconus Evidence:

  • Serial corneal topography showing steepening over time (minimum 2 exams, 3-6 months apart)
  • Kmax measurements documenting increased maximum corneal curvature
  • Pachymetry readings showing corneal thinning progression
  • Clinical notes from your ophthalmologist describing symptom progression
Tip: Most insurance plans require objective evidence of progression, not just symptoms. Work with your doctor to ensure you have at least two sets of corneal imaging taken months apart.

Additional Requirements:

  • Confirmed diagnosis of progressive keratoconus (ICD-10: H18.601-H18.609)
  • Documentation that corneal thickness is ≥400 microns (minimum for safe cross-linking)
  • Confirmation the procedure will use FDA-approved Photrexa with iLink (KXL) system
  • Prior treatment history (if any)

Forms and Contacts

  • Aetna prior authorization form (available through provider portal)
  • Clinical notes from your ophthalmologist
  • Imaging studies (topography, pachymetry reports)
  • Insurance card and member ID

Submit the Prior Authorization Request

Step-by-Step Submission Process

  1. Your doctor's office initiates the prior authorization request
  2. Submit via Aetna provider portal (fastest method) or fax to the number provided in your plan documents
  3. Include complete documentation packet:
    • Completed PA form
    • Clinical notes showing progression
    • All corneal imaging studies
    • Confirmation of FDA-approved protocol
Note: Incomplete submissions are the #1 cause of delays. Ensure all required documents are included in the initial submission.

What Happens Next

  • Aetna reviews the request within 15 business days (standard)
  • You may receive requests for additional information
  • Approval letters typically include specific facility and procedure codes

Follow-Up and Timelines

Standard Timeline

  • Initial review: 15 business days from complete submission
  • Additional information requests: 5-10 business days to respond
  • Final decision: Within 30 days of initial request

When to Follow Up

Call Aetna at 1-855-240-0535 (verify current number on your insurance card) if:

  • No response after 20 business days
  • You receive a request for information already submitted
  • You need expedited review due to rapidly progressing disease

Sample Follow-Up Script

"Hi, I'm calling to check on prior authorization request #[reference number] for Photrexa corneal cross-linking submitted on [date]. Can you tell me the current status and whether any additional information is needed?"

If You're Asked for More Information

Common Requests

  • More recent imaging: Aetna may want topography within the last 3 months
  • Specialist consultation notes: Detailed progression assessment from corneal specialist
  • Treatment history: Documentation of any prior keratoconus treatments

Medical Necessity Documentation

Your doctor should provide a letter explaining:

  • Why cross-linking is medically necessary now
  • How progression has been documented objectively
  • Why FDA-approved protocol is appropriate
  • Expected outcomes and vision preservation goals

If Denied: Appeal Process

Common Denial Reasons and Solutions

Denial Reason How to Address
"Insufficient progression documentation" Submit additional topography studies showing clear Kmax increase
"Non-formulary procedure" Request formulary exception with medical necessity letter
"Experimental/investigational" Emphasize FDA approval and provide agency documentation
"Out-of-network facility" Request network exception or find in-network provider

Internal Appeal Process

  • Timeline: File within 180 days of denial
  • Method: Submit via Aetna appeals department (contact info on denial letter)
  • Documentation: Include all original materials plus additional supporting evidence
  • Decision timeframe: 30 days for standard appeals, 72 hours for expedited

Expedited Appeals

Request expedited review if your doctor certifies that delay would:

  • Significantly worsen your keratoconus progression
  • Risk permanent vision loss
  • Cause serious deterioration in your health

Pennsylvania External Review Process

If Aetna denies your internal appeal, Pennsylvania offers a state-supervised external review program that overturns approximately 50% of denials.

How It Works

  1. Obtain Final Adverse Benefit Determination from Aetna's internal appeal
  2. File external review request within 4 months via Pennsylvania Insurance Department
  3. Independent review organization (IRO) reviews your case
  4. Decision timeline: 45 days for standard review, 72 hours for expedited
  5. Binding decision: If IRO approves, Aetna must cover the treatment

Contact Information

  • Pennsylvania Insurance Department: 1-877-881-6388
  • Email: [email protected]
  • Online portal: Available at PA.gov for form submission
From our advocates: We've seen patients succeed in external review by submitting additional peer-reviewed studies showing cross-linking effectiveness for their specific type of keratoconus progression. The independent reviewers often have more clinical expertise than initial reviewers and appreciate comprehensive medical literature supporting the treatment decision.

Costs and Financial Assistance

Typical Out-of-Pocket Costs

  • With Aetna coverage: Usually $0-200 copay per eye
  • Without coverage: $2,500-4,000 per eye for complete procedure

Financial Assistance Options

  • Glaukos patient assistance: Contact manufacturer for potential copay support
  • CareCredit: Healthcare financing for approved patients
  • Hospital financial assistance: Many facilities offer payment plans

For current assistance programs, visit Glaukos patient resources (verify eligibility requirements).

FAQ

How long does Aetna prior authorization take for Photrexa in Pennsylvania? Standard review takes 15 business days from complete submission. Expedited reviews (if medically urgent) are completed within 72 hours.

What if Photrexa is non-formulary on my Aetna plan? Request a formulary exception with medical necessity documentation. Emphasize FDA approval and lack of equivalent alternatives.

Can I get an expedited appeal if my keratoconus is progressing rapidly? Yes, if your doctor certifies that delay would worsen your condition or risk vision loss, you can request expedited review within 72 hours.

Does Aetna require step therapy for keratoconus treatment? Typically no, since Photrexa cross-linking is often the first-line treatment for progressive keratoconus. However, document any prior treatments attempted.

What happens if my appeal is denied by Aetna? You can file for external review with Pennsylvania's Insurance Department within 4 months. This independent review process overturns about 50% of denials.

Are there alternatives if Photrexa isn't covered? FDA-approved cross-linking with Photrexa is the gold standard. Non-FDA protocols may not be covered and lack the same safety oversight.

Printable Checklist

Before Starting:

  • Verify ophthalmologist is in Aetna network
  • Confirm surgical facility accepts Aetna
  • Obtain member ID and plan details

Documentation to Gather:

  • Serial corneal topography (2+ studies showing progression)
  • Kmax measurements over time
  • Pachymetry readings
  • Clinical notes from ophthalmologist
  • Insurance card copy

Submission:

  • Complete Aetna PA form
  • Submit via provider portal
  • Include all supporting documents
  • Get reference number for tracking

Follow-Up:

  • Call after 20 business days if no response
  • Respond promptly to requests for additional information
  • Document all communications with reference numbers

If Denied:

  • File internal appeal within 180 days
  • Consider expedited review if urgent
  • Prepare for Pennsylvania external review if needed

When navigating complex insurance requirements, Counterforce Health can help analyze denial letters and create targeted appeals that address each plan's specific criteria, potentially turning denials into approvals with the right evidence and documentation strategy.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage decisions depend on your specific plan terms and medical circumstances. Always consult your healthcare provider about treatment options and work with your insurance company to understand your benefits. For assistance with insurance appeals in Pennsylvania, contact the Pennsylvania Insurance Department at 1-877-881-6388.

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