By Counterforce Health Team in Revcovi (elapegademase) —

How to Get Revcovi (Elapegademase) Covered by Aetna (CVS Health) in Washington: Complete Appeals Guide

Answer Box: Getting Revcovi Covered by Aetna in Washington

Revcovi (elapegademase) requires prior authorization from Aetna (CVS Health). To get coverage in Washington: (1) Your immunologist submits a PA request with ADA-SCID genetic confirmation and documentation of failed/contraindicated bone marrow transplant, (2) If denied, file internal appeal within 30-60 days, (3) Request external review through Washington's IRO process within 60 days of final denial. Standard decisions take 30-45 days; expedited reviews complete within 72 hours for urgent cases. Start by gathering your genetic test results and transplant eligibility documentation.

Table of Contents

Coverage Basics

Is Revcovi Covered by Aetna?

Revcovi (elapegademase-lvlr) is covered by Aetna (CVS Health) plans but requires prior authorization. As the only FDA-approved enzyme replacement therapy for adenosine deaminase severe combined immunodeficiency (ADA-SCID), it's typically covered when medical necessity criteria are met.

The medication costs approximately $11,851 for 1.5 mL (directional cash price), making prior authorization essential for most patients. Actual costs vary based on dosing, which is calculated by weight and clinical response.

Which Aetna Plans Cover Revcovi?

Most Aetna commercial plans, Medicare Advantage, and Medicaid managed care plans cover Revcovi when medically necessary. Coverage specifics depend on your formulary tier and benefit design. Check your Aetna precertification list for current requirements.

Prior Authorization Process

Who Submits the PA Request?

Your prescribing physician (typically an immunologist or pediatric immunologist) submits the prior authorization request. Aetna recommends submitting requests at least two weeks in advance through the Availity provider portal or electronic medical record (EMR) system.

Step-by-Step: Fastest Path to Approval

  1. Confirm ADA-SCID diagnosis - Your immunologist documents genetic testing results confirming adenosine deaminase deficiency
  2. Document transplant status - Provide evidence that bone marrow transplant failed, was contraindicated, or is unavailable
  3. Gather clinical records - Collect immune function tests, infection history, and current clinical status
  4. Submit PA request - Physician submits through Availity portal with complete documentation
  5. Track submission - Monitor request status through provider portal
  6. Follow up if needed - Respond promptly to requests for additional information
  7. Receive determination - Standard decisions within 30-45 days, expedited within 72 hours

Timing and Deadlines

How Long Does Prior Authorization Take?

  • Standard PA decisions: 30-45 days from complete submission
  • Expedited/urgent requests: 72 hours when clinical urgency is documented
  • Incomplete submissions: May result in delays or automatic denials

For urgent situations where delayed treatment could seriously jeopardize your health, your doctor can request expedited review by documenting medical urgency.

Appeal Deadlines in Washington

If your PA is denied:

  • Internal appeals: 30 days (if service not received) or 60 days (if seeking reimbursement)
  • External review request: Within 60 days of final internal denial
  • Expedited appeals: 72 hours for urgent cases
Tip: Mark these deadlines on your calendar immediately after receiving a denial notice.

Medical Necessity Criteria

What Documentation Does Aetna Require?

Based on similar state Medicaid criteria, Aetna typically requires:

Diagnosis Confirmation:

  • Genetic testing confirming ADA-SCID
  • Laboratory evidence of adenosine deaminase deficiency
  • Documentation of severe combined immunodeficiency

Treatment History:

  • Evidence that hematopoietic stem cell transplant has failed, is contraindicated, or unavailable
  • Documentation of current immune status
  • Previous treatments attempted (if any)

Clinical Management:

  • Care managed by immunologist or pediatric immunologist
  • Monitoring plan for ADA activity levels and immune reconstitution
  • Dosing based on weight (typically ≤0.4 mg/kg/week)

Clinician Corner: Medical Necessity Letter Checklist

Healthcare providers should include:

  • Problem statement: ADA-SCID diagnosis with genetic confirmation
  • Clinical rationale: Why Revcovi is medically necessary vs. alternatives
  • Treatment history: Documentation of transplant failure/contraindication
  • Monitoring plan: How ADA activity and immune function will be tracked
  • Dosing justification: Weight-based dosing rationale
  • Guidelines: Reference to FDA labeling and immunodeficiency treatment guidelines

Understanding Costs

Copay vs. Coinsurance

Your out-of-pocket costs depend on your specific Aetna plan:

  • Copay plans: Fixed dollar amount per prescription (e.g., $50-$100)
  • Coinsurance plans: Percentage of drug cost (e.g., 20% after deductible)
  • High-deductible plans: Full cost until deductible met, then coinsurance applies

Given Revcovi's high cost, coinsurance plans may result in significant out-of-pocket expenses even after approval.

Denials and Appeals

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Not medically necessary" Provide genetic testing, immune function data ADA deficiency confirmation, SCID documentation
"Experimental/investigational" Cite FDA approval, established indication FDA label, peer-reviewed studies
"Alternative treatments available" Document transplant failure/contraindication Transplant evaluation, medical contraindications
"Incorrect dosing" Provide weight-based calculation rationale Dosing guidelines, patient weight, clinical response
"Missing specialist oversight" Confirm immunologist management Specialist consultation notes, treatment plan

When Your Initial PA is Denied

Don't panic—many denials are overturned on appeal with proper documentation. Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing the specific denial reason and crafting point-by-point rebuttals aligned to the plan's own rules.

Renewals and Reauthorization

When to Request Reauthorization

Most PA approvals for Revcovi last 6-12 months. Your healthcare team should:

  • Submit renewal requests 30-60 days before expiration
  • Include updated lab results showing treatment response
  • Document continued medical necessity
  • Provide any changes in clinical status or dosing

What Changes Trigger New PA Requirements?

  • Significant dose increases beyond approved amounts
  • Changes in administration frequency
  • Switching between different formulations
  • Changes in prescribing physician

Specialty Pharmacy Requirements

Why Was My Prescription Transferred?

Aetna typically requires specialty medications like Revcovi to be dispensed through CVS Specialty Pharmacy or other contracted specialty pharmacies. This ensures:

  • Proper cold-chain storage and handling
  • Patient education and support services
  • Coordination with your healthcare team
  • Insurance benefit optimization

Administration Requirements

Revcovi must be given as intramuscular injection only—never intravenously or by infusion. The medication:

  • Cannot be diluted or mixed with other drugs
  • Must reach room temperature before injection
  • Requires polypropylene syringes for preparation
  • Should be administered immediately after preparation

Troubleshooting Common Issues

Provider Portal Problems

If your doctor can't access the Availity portal or PA forms:

  • Contact Aetna Provider Services at the number on your insurance card
  • Request PA forms be sent via fax or mail
  • Ask for alternative submission methods

Missing Prior Authorization Forms

If PA requests are incomplete:

  • Aetna will typically request additional information within 5-10 business days
  • Respond promptly to avoid automatic denials
  • Submit all requested documentation at once to prevent further delays

Appeals Playbook for Washington

Internal Appeals Process

Level 1 Internal Appeal:

  • Deadline: 30 days (services not received) or 60 days (reimbursement)
  • How to file: Submit written appeal to address on denial notice
  • Timeline: Decision within 30 days (standard) or 72 hours (expedited)
  • Required: Copy of denial notice, additional medical records, physician letter

Level 2 Internal Appeal (if available):

  • Deadline: 30 days from Level 1 denial
  • Process: Similar to Level 1 with independent reviewer
  • Timeline: 30 days for decision

External Review Through Washington's IRO Process

If internal appeals fail, Washington residents can request external review through an Independent Review Organization (IRO).

Key Details:

  • Deadline: Within 60 days of final internal denial
  • Process: Submit request to Aetna, who assigns certified IRO
  • Timeline: 20 days (fully-insured plans) or 45 days (self-insured plans)
  • Expedited: 72 hours for urgent cases
  • Binding: IRO decision is final and binding on Aetna

To Request External Review:

  1. Contact Aetna member services to request external review
  2. Submit any additional medical records within 5 business days
  3. Track timeline—decisions must come within state-mandated timeframes
  4. If IRO overturns denial, Aetna must provide coverage

Washington Office of Insurance Commissioner Support

For assistance with appeals or complaints:

The OIC can help you navigate the appeals process and file complaints if insurers don't follow proper procedures.

Financial Assistance Options

Manufacturer Support Programs

Chiesi Total Care Copay Program:

  • Eligible patients may pay as little as $0 per prescription
  • Requirements: Valid prescription, not on federal/state-funded plans, meet income criteria
  • Apply: chiesitotalcare.com

Patient Assistance Program:

  • Free medication for uninsured/underinsured patients
  • Financial and insurance eligibility requirements apply
  • Enrollment through Chiesi Total Care

Foundation Grants and Support

Many rare disease foundations provide financial assistance for ADA-SCID treatments. Contact patient advocacy organizations for immunodeficiency disorders for additional resources.

FAQ

How long does Aetna prior authorization take for Revcovi in Washington? Standard PA decisions take 30-45 days from complete submission. Expedited requests for urgent medical situations are decided within 72 hours.

What if Revcovi is non-formulary on my Aetna plan? Non-formulary medications can still be covered through formulary exceptions. Your doctor submits medical necessity documentation explaining why formulary alternatives aren't appropriate.

Can I request an expedited appeal if my PA is denied? Yes, if delayed treatment could seriously jeopardize your health. Your doctor must document medical urgency, and expedited appeals are decided within 72 hours.

Does step therapy apply to Revcovi? Aetna's published step therapy lists don't specifically mention Revcovi, likely because it's the only FDA-approved enzyme replacement therapy for ADA-SCID and pegademase bovine (Adagen) is no longer available.

What happens if the external IRO review denies coverage? IRO decisions are binding on insurance companies. If denied, you can file a complaint with the Washington Office of Insurance Commissioner or consult legal counsel for further options.

How do I find out my specific Aetna plan's coverage for Revcovi? Check your plan's formulary or call member services using the number on your insurance card. You can also review Aetna's precertification lists.

Can I get help with the appeals process? Yes. Counterforce Health specializes in helping patients and clinicians create evidence-backed appeals. Washington's Office of Insurance Commissioner also provides free consumer assistance at 800-562-6900.

What if my employer plan is self-funded? Self-funded employer plans may have different appeal timelines (45 days for external review vs. 20 days for fully-insured plans). Contact your HR department or the U.S. Department of Labor for ERISA plan appeals guidance.

Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to create point-by-point rebuttals with the right clinical evidence and procedural requirements for each payer's specific workflow.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific insurance plan and clinical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For assistance with appeals in Washington, contact the Office of Insurance Commissioner at 800-562-6900.

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