How to Get Rezlidhia (Olutasidenib) Covered by Aetna CVS Health in Illinois: Complete Prior Authorization and Appeals Guide
Answer Box: Getting Rezlidhia (Olutasidenib) Covered by Aetna CVS Health in Illinois
Rezlidhia (olutasidenib) requires prior authorization from Aetna CVS Health. Your hematologist/oncologist must document IDH1 mutation, relapsed/refractory AML diagnosis, and prior treatment failures. If denied, you have 180 days to appeal internally, then 4 months for Illinois external review. Start today: Ask your doctor to submit the PA with complete molecular testing and treatment history. Contact CVS Specialty at enrollment to coordinate benefits verification and patient assistance programs.
Table of Contents
- Coverage Requirements at a Glance
- Step-by-Step: Fastest Path to Approval
- Common Denial Reasons & How to Fix Them
- Appeals Playbook for Illinois
- Scripts & Templates
- Patient Assistance & Cost Support
- When to Escalate to Illinois Regulators
- Frequently Asked Questions
Coverage Requirements at a Glance
Requirement | What It Means | Where to Find It | Source |
---|---|---|---|
Prior Authorization | Required before dispensing | Aetna member portal or provider services | Aetna PA Process |
IDH1 Mutation | FDA-approved test confirming mutation | Molecular pathology report | FDA Label |
Specialist Prescriber | Hematologist/oncologist required | Board certification verification | Cigna Coverage Policy |
Diagnosis | Relapsed/refractory AML | ICD-10 codes in medical records | FDA Indication |
Treatment History | Documentation of prior therapies | Clinic notes, infusion records | Standard PA requirements |
Step-by-Step: Fastest Path to Approval
1. Confirm IDH1 Mutation Testing (Patient + Clinic)
Your oncologist needs an FDA-approved IDH1 mutation test result. If not already done, request this immediately—it's mandatory for coverage.
Timeline: 3-7 days for results
Submit: Include molecular pathology report with PA
2. Gather Complete Treatment History (Clinic Staff)
Document all prior AML therapies: drug names, dates, durations, and reasons for discontinuation (progression, toxicity, contraindication).
Timeline: 1-2 days to compile records
Submit: Detailed treatment timeline in PA form
3. Submit Prior Authorization (Prescriber)
Your hematologist submits the PA through Aetna's provider portal or fax. Include IDH1 test, diagnosis confirmation, treatment history, and medical necessity letter.
Timeline: Same day submission
Expected decision: 15-30 days standard, 72 hours expedited
4. Enroll with CVS Specialty (Patient)
While PA is pending, complete CVS Specialty enrollment for benefits verification and patient assistance screening.
Timeline: 1-2 days for enrollment
Benefits verification: 5-10 business days
5. Track PA Status (Patient + Clinic)
Monitor through Aetna member portal or provider services. If no decision within timeframes, call to request status update.
Contact: Aetna member services (verify current number on insurance card)
6. If Approved: Coordinate Delivery
CVS Specialty will schedule delivery once PA is approved. Confirm delivery address and timing.
Delivery: Home delivery available throughout Illinois
7. If Denied: File Appeal Immediately
Don't wait—start internal appeal within 180 days. Consider peer-to-peer review and gather additional evidence.
Forms: Aetna appeal forms
Common Denial Reasons & How to Fix Them
Denial Reason | How to Overturn | Required Documentation |
---|---|---|
IDH1 mutation not documented | Submit FDA-approved test results | Molecular pathology report with clear IDH1 mutation identification |
Non-specialist prescriber | Transfer to hematologist/oncologist | Board-certified specialist must submit new PA |
Incomplete treatment history | Provide detailed prior therapy records | Drug names, dates, outcomes, reasons for discontinuation |
"Not medically necessary" | Submit evidence-based appeal | NCCN guidelines, FDA label, peer-reviewed studies |
Step therapy not met | Document contraindications to preferred agents | Medical records showing intolerance or failure of alternatives |
Appeals Playbook for Illinois
Internal Appeals with Aetna CVS Health
Timeline: 180 days from denial notice
Standard review: 30 days for decision
Expedited review: 72 hours for urgent cases
How to file:
- Complete Aetna appeal form
- Include all medical records, treatment history, and new evidence
- Submit via member portal, fax, or mail (verify current submission methods)
Tip: Request a peer-to-peer review as part of your appeal. Your oncologist can speak directly with an Aetna medical director within 14 days of denial.
Illinois External Review
If internal appeals fail, Illinois law guarantees independent external review.
Timeline: Must request within 4 months of final internal denial
Decision: Within 45 days (72 hours for expedited)
Cost: Free to consumers
How to file:
- Complete Illinois Department of Insurance External Review Form
- Submit by email ([email protected]), fax (217-557-8945), or mail:Illinois Department of Insurance
Office of Consumer Health Insurance
External Review Request
320 W. Washington Street
Springfield, IL 62767 - Include denial letters, appeal decisions, and all medical records
Help available: OCHI Helpline at 877-850-4740
Scripts & Templates
Patient Phone Script for Aetna CVS Health
"Hello, I'm calling about my prior authorization request for Rezlidhia (olutasidenib). My member ID is [ID number]. Can you please provide the status and let me know if any additional information is needed? If there are delays, I'd like to request expedited review since this is for relapsed AML treatment."
Medical Necessity Letter Template
Healthcare providers can use this framework:
This patient has relapsed/refractory acute myeloid leukemia (ICD-10: [code]) with confirmed IDH1 mutation per FDA-approved testing [date, lab]. Prior therapies included [specific agents, dates, outcomes]. Rezlidhia (olutasidenib) is FDA-approved for this exact indication and represents standard care per NCCN guidelines. Alternative therapies are contraindicated due to [specific reasons]. Treatment will include appropriate safety monitoring per prescribing information.
Patient Assistance & Cost Support
Manufacturer Support
Rigel Pharmaceuticals may offer patient assistance programs for eligible patients. Contact information available through your oncologist or CVS Specialty enrollment.
Foundation Grants
Several organizations provide grants for cancer medications:
- Leukemia & Lymphoma Society
- CancerCare Co-Payment Assistance Foundation
- Patient Access Network Foundation
Eligibility: Varies by income, insurance status, and diagnosis
CVS Specialty Financial Support
CVS Specialty's care team helps identify and apply for available assistance programs during enrollment, including copay cards and charitable foundations.
When to Escalate to Illinois Regulators
Contact Illinois regulators if you experience:
- Unreasonable delays in PA decisions
- Repeated denials without clear medical rationale
- Failure to provide required appeal information
Illinois Department of Insurance
OCHI Helpline: 877-850-4740
File complaints: Illinois DOI website
Illinois Attorney General Health Care Helpline: 1-877-305-5145
Assists with insurance problems and can intervene informally with insurers.
Frequently Asked Questions
How long does Aetna CVS Health prior authorization take in Illinois?
Standard PA decisions: 15-30 days. Expedited requests (for urgent cases): 72 hours. Track status through member portal or by calling member services.
What if Rezlidhia is not on Aetna's formulary?
You can request a formulary exception with medical necessity documentation. Your oncologist must demonstrate why Rezlidhia is medically necessary over formulary alternatives.
Can I request an expedited appeal?
Yes, if delays would seriously jeopardize your health. Aetna must decide expedited appeals within 72 hours. Your oncologist should clearly document the urgency.
Does step therapy apply if I've tried treatments outside Illinois?
Yes, treatment history from any location counts. Provide complete documentation of all prior therapies, regardless of where they were received.
What happens if my external review is approved?
The decision is binding—Aetna must cover the treatment. External review decisions cannot be appealed by the insurer.
How much does Rezlidhia cost without insurance?
List price is approximately $32,000 per month. Patient assistance programs and copay support may be available for eligible patients.
From Our Advocates
We've seen cases where initial Rezlidhia denials were overturned simply by submitting the complete IDH1 mutation testing report and detailed prior treatment timeline. The key is ensuring your oncologist includes every piece of required documentation upfront—it prevents delays and reduces the need for appeals. Most successful approvals happen when the molecular pathology report clearly identifies the IDH1 mutation and the medical necessity letter directly addresses Aetna's coverage criteria.
At Counterforce Health, we help patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and payer policies to draft point-by-point rebuttals that align with each plan's specific requirements, pulling the right clinical evidence and citations to support coverage decisions.
If you're facing a complex denial or need help navigating the appeals process, Counterforce Health can provide the specialized support needed to get critical medications like Rezlidhia approved by payers like Aetna CVS Health.
Sources & Further Reading
- Aetna Appeals and Disputes Overview
- Illinois Department of Insurance External Review Process
- Illinois External Review Form (PDF)
- CVS Specialty Enrollment Forms
- Rezlidhia FDA Prescribing Information
- OCHI Consumer Helpline - 877-850-4740
Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for guidance specific to your situation. Coverage policies and procedures may change—verify current requirements with your insurer.
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