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

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

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

Aetna CVS Health covers Photrexa (riboflavin ophthalmic solution) for corneal cross-linking in progressive keratoconus, but requires prior authorization with documented progression. Key requirements: serial corneal topography showing ≥1 diopter Kmax increase over 12 months, minimum corneal thickness ≥400 microns, and use of the FDA-approved iLink® system. Submit via Aetna's provider portal at least 2 weeks before your procedure. If denied, Texas law provides strong appeal rights including independent external review within 180 days.

First step today: Schedule an eye exam to document current topography and gather 6+ months of progression data for your prior authorization.

Table of Contents

  1. Aetna's Coverage Policy Overview
  2. Medical Necessity Requirements
  3. Step Therapy and Exceptions
  4. Required Documentation
  5. Specialty Pharmacy and Site of Care
  6. Evidence to Support Your Case
  7. Common Denial Reasons and Solutions
  8. Texas Appeals Process
  9. Cost and Financial Assistance
  10. FAQ

Aetna's Coverage Policy Overview

Aetna CVS Health covers Photrexa (riboflavin ophthalmic solution) for FDA-approved corneal collagen cross-linking in progressive keratoconus and post-refractive ectasia. The drug works with the iLink® UVA system to strengthen corneal tissue through epithelium-off cross-linking.

Plan Types That Cover Photrexa:

  • Commercial HMO/PPO plans
  • Medicare Advantage (Part C)
  • Some Medicaid managed care plans

What's Not Covered:

  • Epithelium-on (epi-on) cross-linking procedures
  • Non-FDA approved systems
  • Procedures deemed experimental or investigational
Note: Coverage varies by specific plan. Always verify with Aetna member services at 1-800-872-3862 before scheduling your procedure.

Medical Necessity Requirements

Aetna requires documented progressive keratoconus or corneal ectasia with specific clinical criteria:

Coverage Requirements Table

Requirement Criteria Documentation Needed
Diagnosis Progressive keratoconus (ICD-10: H18.601-H18.609) Clinical exam notes, topography
Progression ≥1.0 D Kmax increase over 12-24 months Serial corneal topography
Corneal Thickness ≥400 microns (pre-epithelium removal) Pachymetry results
Visual Impact Documented decline in best-corrected vision Visual acuity records
FDA Protocol Epithelium-off cross-linking only iLink® system confirmation
Prior Authorization Required for all cases Complete PA submission

ICD-10 Codes for Keratoconus

  • H18.601: Keratoconus, unspecified, right eye
  • H18.602: Keratoconus, unspecified, left eye
  • H18.603: Keratoconus, unspecified, bilateral
  • H18.611: Keratoconus, stable, right eye
  • H18.612: Keratoconus, stable, left eye
  • H18.613: Keratoconus, stable, bilateral

Step Therapy and Exceptions

Most Aetna plans require documentation of failed conservative management before approving Photrexa:

Required Prior Treatments:

  1. Glasses correction - Document inadequate vision improvement
  2. Rigid gas permeable contact lenses - Show intolerance or inadequate fit
  3. Specialty contact lenses - Scleral or hybrid lens failures

Medical Exception Pathways

You can bypass step therapy requirements if you have:

  • Contraindications to contact lens wear (severe dry eye, allergies)
  • Intolerance documented by your eye doctor
  • Rapid progression requiring immediate intervention

How to Request Step Therapy Override:

  • Submit medical exception request to: Aetna PA, 1300 E. Campbell Rd., Richardson, TX 75081
  • Include physician letter documenting contraindications or failures
  • Call 1-855-582-2025 for expedited processing

Required Documentation

Essential Documents for Prior Authorization

Clinical Documentation:

  • Complete eye examination notes
  • Serial corneal topography (minimum 2 exams, 6+ months apart)
  • Pachymetry measurements
  • Visual acuity testing results
  • Contact lens fitting records (if applicable)

Progression Evidence:

  • Quantified Kmax changes (e.g., "Kmax increased from 52.3D to 54.8D over 8 months")
  • Corneal thickness measurements
  • Visual acuity decline documentation
  • Refractive changes
Clinician Corner: Your medical necessity letter should include: (1) specific progression metrics, (2) failed conservative treatments, (3) contraindications to alternatives, (4) expected treatment goals, and (5) references to AAO guidelines supporting cross-linking for progressive keratoconus.

Specialty Pharmacy and Site of Care

CVS Specialty Pharmacy Requirements

Photrexa is typically dispensed through CVS Specialty Pharmacy after prior authorization approval:

Ordering Process:

  1. Prior authorization approved by Aetna
  2. Prescription sent to CVS Specialty
  3. Drug delivered to treatment facility 2-3 days before procedure
  4. Procedure performed at approved facility

Approved Texas Facilities

Texas facilities offering FDA-approved iLink corneal cross-linking include:

  • Whitsett Vision Group (Houston)
  • KE Eye Centers of Texas (multiple locations)
  • Houston Eye Associates (Houston)
  • Lake Austin Eye (Austin)
  • Parkhurst NuVision (San Antonio)
Tip: Verify your chosen facility is in Aetna's network before scheduling. Out-of-network facilities may result in coverage denial.

Evidence to Support Your Case

Key Clinical Guidelines

American Academy of Ophthalmology (AAO):

  • Supports cross-linking for progressive keratoconus
  • Recommends epithelium-off protocol for maximum efficacy
  • Emphasizes importance of progression documentation

FDA Approval Basis:

  • Clinical trials showing halted progression in 96% of patients
  • Safety profile established for epithelium-off protocol
  • Approved for Kmax ≤65 diopters, corneal thickness ≥400 microns

Supporting Literature

Include these evidence types in appeals:

  • FDA labeling for Photrexa and iLink system
  • Peer-reviewed studies on cross-linking efficacy
  • AAO Preferred Practice Pattern guidelines
  • International consensus on keratoconus management

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Incomplete progression data Submit serial topography with quantified changes 2+ exams showing ≥1D Kmax increase
Non-FDA system Confirm iLink® system use Facility confirmation letter
Lack of medical necessity Strengthen clinical rationale Detailed physician letter with progression metrics
Step therapy not met Document failed alternatives Contact lens fitting records, intolerance notes
Out-of-network facility Find in-network provider or request exception Network status verification

Sample Appeal Language

"Patient presents with documented progressive keratoconus with Kmax progression from [X]D to [Y]D over [timeframe], representing a [Z]D increase exceeding clinical thresholds for intervention. Conservative management with rigid gas permeable lenses has failed due to [specific reason]. Cross-linking with Photrexa represents the only FDA-approved therapeutic intervention to halt disease progression and prevent need for corneal transplantation."

Texas Appeals Process

Texas provides robust patient rights for insurance appeals, including independent external review.

Internal Appeal Process

Timeline: File within 180 days of denial Decision: 30 days for pre-service requests How to File:

  • Online: Aetna member portal
  • Phone: 1-800-872-3862
  • Mail: Address on your denial letter

External Review Rights

If your internal appeal is denied, Texas law provides independent external review:

Eligibility:

  • Denial based on medical necessity
  • Treatment deemed experimental/investigational
  • Final internal appeal denial received

Timeline:

  • Request within 4 months of final denial
  • Decision within 20 days (5 days for urgent cases)
  • Review is binding on Aetna

How to Request:

  • Use IRO request form provided with denial
  • Submit to Texas Department of Insurance
  • Call TDI at 1-866-554-4926 for guidance
Texas-Specific Advantage: You can request expedited external review concurrently with an expedited internal appeal if delay would jeopardize your health.

Getting Help in Texas

Texas Department of Insurance:

  • Consumer hotline: 1-800-252-3439
  • Website: tdi.texas.gov
  • Appeals guidance and complaint filing

Office of Public Insurance Counsel (OPIC):

  • Help line: 1-877-611-6742
  • Detailed appeals guidance
  • Consumer advocacy

For patients seeking expert assistance with prior authorizations and appeals, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer-specific requirements, helping patients access necessary treatments like Photrexa more efficiently.

Cost and Financial Assistance

Expected Costs

  • With Insurance: Copay/coinsurance typically $500-$1,500 per eye
  • Without Coverage: $2,500-$4,000 per eye (procedure + facility fees)

Financial Assistance Options

Manufacturer Support:

  • Contact Glaukos patient assistance programs
  • Income-based eligibility requirements may apply

Payment Plans:

  • Many facilities offer financing options
  • CareCredit and other medical credit options available

FAQ

How long does Aetna prior authorization take in Texas? Standard decisions take 24-48 hours to 30 days. Expedited reviews are completed within 72 hours with urgency documentation.

What if Photrexa is non-formulary on my plan? Request a formulary exception through Aetna's medical exception process. Include clinical rationale for why covered alternatives are inappropriate.

Can I appeal if my procedure was already performed? Yes, you can appeal post-service denials within 180 days. Include all clinical documentation and medical necessity justification.

Does step therapy apply if I failed treatments outside Texas? Previous treatment records from other states are generally accepted. Provide comprehensive documentation of failed therapies.

What happens if I miss the appeal deadline? Contact Aetna immediately to request good cause exception. Valid reasons include not receiving proper notice or serious illness preventing timely filing.

Is epi-on cross-linking ever covered? Epithelium-on cross-linking is typically denied as experimental. Focus on FDA-approved epithelium-off protocol for best coverage chances.

Key Takeaways

Getting Photrexa covered by Aetna CVS Health in Texas requires careful preparation and documentation. Success depends on demonstrating clear progression through serial topography, meeting FDA-approved protocol requirements, and providing comprehensive clinical justification. Counterforce Health's specialized approach to insurance appeals can help ensure your case is presented with the strongest possible evidence and payer-specific strategy.

Remember that Texas provides excellent patient protection through its appeals process, including binding external review. Don't hesitate to use these rights if your initial request is denied.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage determinations. Coverage policies and requirements may change; verify current information with Aetna CVS Health directly.

Sources & Further Reading

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