By Counterforce Health Team in Revcovi (elapegademase) —

How to Get Revcovi (elapegademase) Covered by Aetna CVS Health in Virginia: Complete PA Guide with Forms and Appeal Steps

Answer Box: Getting Revcovi Covered by Aetna CVS Health in Virginia

Revcovi (elapegademase) requires prior authorization from Aetna CVS Health but is covered on the specialty tier for confirmed ADA-SCID cases. Submit a complete PA packet including genetic/enzyme testing, specialist documentation, and transplant failure evidence through the Aetna provider portal. Standard approval takes 24-48 hours; expedited decisions within 72 hours if medically urgent. If denied, Virginia's Bureau of Insurance provides external review within 45 days (72 hours expedited).

First step today: Have your immunologist verify your Aetna plan type and submit the PA packet via the provider portal with complete diagnostic documentation.

Table of Contents

  1. Plan Types & Network Requirements
  2. Formulary Status & Tier Placement
  3. Prior Authorization Requirements
  4. CVS Specialty Pharmacy Setup
  5. Cost Sharing & Financial Assistance
  6. Submission Process & Timelines
  7. Appeals Process in Virginia
  8. Common Approval Patterns
  9. When to Escalate
  10. FAQ

Plan Types & Network Requirements

Aetna CVS Health offers several plan types in Virginia, each with different referral and network requirements for Revcovi coverage:

Commercial Plans (HMO/PPO/EPO)

  • HMO plans require primary care referrals to immunology specialists
  • PPO/EPO plans allow direct specialist access but in-network providers reduce costs
  • All plans require PA for Revcovi regardless of network status

Medicare Advantage

  • Follow Medicare Part B coverage rules for specialty injectables
  • May have additional step therapy requirements
  • Expedited appeals available for urgent medical needs

Medicaid Plans

  • Virginia expanded Medicaid covers specialty drugs with PA
  • May require state-specific forms in addition to Aetna requirements
Tip: Check your member ID card for plan type (HMO, PPO, EPO) and contact member services to confirm specialty pharmacy benefits before starting the PA process.

Formulary Status & Tier Placement

Revcovi sits on Aetna's specialty drug tier for 2025-2026 formularies. Here's what this means:

Coverage Element Status What It Means
Formulary Listed Yes Covered with PA
Tier Placement Specialty Highest cost-sharing tier
PA Required Yes Must prove medical necessity
Step Therapy Case-by-case May require transplant failure documentation
Quantity Limits Per weight/dose Based on FDA dosing guidelines

Key Point: Revcovi is covered under the medical benefit, not pharmacy benefit, due to required clinical administration and cold storage via CVS Specialty.

Alternative Therapies: If Revcovi is denied, your specialist may consider:

  • Hematopoietic stem cell transplant (if eligible)
  • Clinical trial gene therapies
  • Supportive care protocols

Prior Authorization Requirements

Aetna requires comprehensive documentation for Revcovi PA approval. Here's exactly what you need:

Core Documentation Checklist

Diagnosis Confirmation

  • ADA enzyme activity test showing <1% of normal levels
  • Genetic testing confirming pathogenic ADA mutations
  • ICD-10 code D81.3 (ADA-SCID) documented

Specialist Requirements

  • Prescribing immunologist, hematologist/oncologist, or geneticist
  • Current specialist notes (within 30 days)
  • Treatment plan specifying 0.2-0.4 mg/kg weekly IM dosing

Prior Therapy Documentation

  • Bone marrow transplant failure, ineligibility, or contraindication
  • Gene therapy consideration status
  • Previous ADA enzyme replacement attempts (if any)

Clinical Monitoring

  • Current CBC with platelet count ≥50,000/μL
  • Patient weight for dosing calculations
  • Baseline lymphocyte counts

Medical Necessity Letter Template

Your specialist should include these elements in their letter:

  1. Patient presentation: ADA-SCID diagnosis with specific enzyme/genetic results
  2. Treatment rationale: Why Revcovi is medically necessary vs. alternatives
  3. Prior therapy failures: Transplant contraindications or failures
  4. Expected outcomes: Improved immune function, reduced infections
  5. Monitoring plan: Regular lab work, dose adjustments, safety assessments

CVS Specialty Pharmacy Setup

Revcovi must be dispensed through CVS Specialty Pharmacy due to cold storage requirements. Here's the enrollment process:

Six-Step Enrollment Process

  1. Patient Information: Complete demographics, contact details, consent for automated updates
  2. Insurance Details: Medical and prescription coverage, copay assistance enrollment
  3. Diagnosis: ICD-10 code D81.3 with clinical description
  4. Clinical Information: Allergies, current medications, height/weight
  5. Prescription Details: Revcovi strength, dose, quantity, refills
  6. Prescriber Signature: Required authorization for PA submission

Submission Methods

Electronic: Use ePrescribe code 1466033 to CVS Specialty Phone: 1-800-237-2767 (7 days/week) Fax: 1-800-323-2445

Additional Requirement: Patients must also enroll in Chiesi Total Care (manufacturer support program) using their separate enrollment form.

Note: No Virginia-specific setup requirements exist. The standard nationwide CVS Specialty process applies for all patients.

Cost Sharing & Financial Assistance

Revcovi costs approximately $11,851 per 1.5 mL vial, with actual out-of-pocket costs varying by plan design.

Typical Cost Structure

Plan Type Patient Responsibility
Commercial PPO 20-40% coinsurance after deductible
Commercial HMO $50-200 specialty copay
Medicare Advantage 25-33% coinsurance
Medicaid $0-3 copay

Financial Assistance Options

Manufacturer Support: Chiesi Total Care provides:

  • Copay assistance for eligible commercial patients
  • Prior authorization support
  • Adherence monitoring and education

State Programs: Virginia residents may qualify for:

  • Virginia Medicaid (expanded eligibility)
  • State pharmaceutical assistance programs
  • Hospital charity care programs

Foundation Grants: Organizations like Patient Services Inc. and Good Days offer grants for rare disease treatments.

Submission Process & Timelines

Fastest Path to Approval

  1. Verify Coverage (Day 1): Check plan type and specialty pharmacy benefits
  2. Gather Documents (Days 1-3): Collect all diagnostic and clinical records
  3. Submit PA (Day 4): Electronic submission via Aetna provider portal
  4. Track Status (Days 5-7): Monitor for additional information requests
  5. Receive Decision (Days 1-2 post-submission): Standard timeline 24-48 hours
  6. Set Up Specialty Pharmacy (Upon approval): Enroll with CVS Specialty
  7. Coordinate Delivery (Within 1-2 business days): Schedule first shipment

Timeline Expectations

Request Type Standard Timeline Expedited Timeline
Initial PA 24-48 hours 24-72 hours
Additional Info 5 days 24 hours
Internal Appeal 30-60 days 72 hours
External Review 45 days 72 hours

Request expedited review if delay risks serious harm (requires physician documentation).

Appeals Process in Virginia

Virginia provides robust appeal rights through the State Corporation Commission Bureau of Insurance.

Internal Appeals (Aetna)

Timeline: File within 60 days of denial Process: Submit additional evidence, request peer-to-peer review Decision: 30-60 days standard, 72 hours expedited

External Review (Virginia Bureau of Insurance)

Eligibility: Complete internal appeals first Timeline: 120 days from final denial to file Process: Submit Form 216-A with supporting documentation Decision: 45 days standard, 72 hours expedited

Required Documents for External Review

  • Denial notice from Aetna
  • Complete medical records
  • Provider recommendations
  • Plan terms and coverage policies
  • Written explanation of alleged policy violations

Contact Information: Virginia Bureau of Insurance P.O. Box 1157, Richmond, VA 23218 Phone: (804) 371-9747 Email: [email protected]

Virginia Advantage: The state allows expedited external review for cancer treatments without exhausting internal appeals—a provision that may apply to life-threatening immunodeficiency cases.

Common Approval Patterns

Based on successful Revcovi approvals, strong submissions typically include:

Documentation That Works

Genetic Evidence: Clear pathogenic ADA mutations with clinical correlation Specialist Expertise: Letters from recognized immunology centers Transplant Status: Detailed explanation of ineligibility or failure Clinical Urgency: Evidence of recurrent infections, failure to thrive Monitoring Plan: Comprehensive safety and efficacy tracking

Red Flags That Cause Denials

  • Incomplete genetic/enzyme testing
  • Off-label use without strong justification
  • Missing transplant consideration documentation
  • Inadequate specialist involvement
  • Unclear dosing rationale
From our advocates: "Patients who succeed often have their immunologist call Aetna directly for a peer-to-peer review when the initial PA is incomplete. This conversation frequently resolves documentation gaps and speeds approval."

When to Escalate

Contact Virginia regulators if you encounter:

  • Repeated denials despite complete documentation
  • Failure to meet Virginia timeline requirements
  • Discrimination based on disability or age
  • Improper application of medical necessity criteria

Virginia State Corporation Commission Bureau of Insurance provides free consumer assistance and can investigate potential violations of state insurance law.

FAQ

How long does Aetna CVS Health PA take in Virginia? Standard PA decisions are made within 24-48 hours. Expedited requests for urgent medical needs are decided within 72 hours.

What if Revcovi is non-formulary on my specific plan? Request a formulary exception with medical necessity documentation. Most ADA-SCID cases qualify due to lack of therapeutic alternatives.

Can I request an expedited appeal in Virginia? Yes, if delay jeopardizes life or health. Your physician must document the urgency. Virginia's external review can be expedited to 72 hours.

Does step therapy apply if I've tried treatments outside Virginia? Yes, Aetna accepts prior therapy documentation from any state. Ensure your Virginia specialist has complete records of previous treatments.

What happens if my appeal is denied? Virginia's external review decision is binding on Aetna. If upheld, consider consultation with a healthcare attorney or patient advocacy organization.

How often do I need PA renewal? Typically every 30-45 days before authorization expires. Include updated labs showing treatment response (trough ADA activity ≥30 mmol/hr/L).

About Counterforce Health: Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Revcovi. Our platform analyzes denial letters, identifies specific coverage criteria, and generates evidence-backed appeals tailored to each payer's requirements—helping patients, clinicians, and specialty pharmacies navigate the prior authorization process more effectively.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and clinical circumstances. Always consult with your healthcare provider and insurance plan for specific guidance. For additional support with Virginia insurance issues, contact the Virginia State Corporation Commission Bureau of Insurance at (804) 371-9747.

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