By Counterforce Health Team in Eylea / Lucentis (aflibercept / ranibizumab) —

Renewing Eylea/Lucentis Approval with Aetna CVS Health in North Carolina: 2024 Timeline and Requirements

Answer Box: Quick Start for North Carolina Residents

If your Eylea or Lucentis authorization is expiring with Aetna CVS Health: Start renewal 30-45 days early. You'll need updated OCT imaging, current visual acuity measurements, and documentation of continued medical necessity. Submit through your eye doctor's office via CVS Caremark (fax: 1-855-330-1720). If denied, North Carolina's Smart NC external review program offers free appeals within 120 days. First step today: Contact your ophthalmologist to schedule OCT imaging and discuss renewal timing.

Table of Contents

  1. Renewal Triggers: When to Start the Process
  2. Evidence Update: What Documentation You'll Need
  3. Renewal Packet: Must-Include Documents
  4. Timeline: Submission and Decision Windows
  5. If Authorization Lapses: Bridge Options
  6. 2024 Annual Changes: What's New
  7. Personal Tracker: Template for Progress
  8. Appeals Process: Smart NC External Review
  9. FAQ

Renewal Triggers: When to Start the Process

Most Aetna CVS Health prior authorizations for Eylea (aflibercept) and Lucentis (ranibizumab) are approved for 6-12 months. You should begin the renewal process 30-45 days before expiration to avoid treatment gaps.

Signs to start early:

  • Your authorization expires within 60 days
  • Your vision has changed significantly
  • You've experienced new side effects
  • Your injection schedule has been modified
  • Your ophthalmologist recommends switching between Eylea and Lucentis
Note: North Carolina Medicaid Tailored Plans currently have relaxed prior authorization requirements through January 31, 2025, but documentation should still be maintained for potential retroactive authorization needs.

Evidence Update: What Documentation You'll Need

Aetna requires specific documentation to demonstrate ongoing medical necessity for anti-VEGF treatments. Your ophthalmologist will need to provide:

Required Clinical Evidence

OCT Imaging:

  • Current optical coherence tomography scan (within 30-60 days)
  • Comparison with baseline and prior scans
  • Documentation of persistent or recurrent disease activity

Visual Acuity Testing:

  • Recent Snellen or ETDRS measurements
  • Comparison with pre-treatment baseline
  • Evidence of stabilization or improvement

Treatment Response Documentation:

  • Response to current therapy
  • Any adverse events or tolerability issues
  • Adherence to injection schedule
  • Justification for continued treatment frequency

Additional Supporting Evidence

  • Updated diagnosis codes (ICD-10)
  • Documentation of contraindications to alternative treatments
  • Evidence of failure or intolerance to step-therapy requirements (if applicable)

Renewal Packet: Must-Include Documents

Your ophthalmologist's office should submit a complete renewal packet including:

  1. Prior Authorization Renewal Form - Available through Aetna provider portal
  2. Letter of Medical Necessity with:
    • Current diagnosis and ICD-10 codes
    • Treatment history and response
    • Current clinical status with OCT and visual acuity results
    • Rationale for continued therapy
  3. Recent OCT Report (within 60 days)
  4. Visual Acuity Records showing current status
  5. Treatment Log documenting injection dates and responses

Letter of Medical Necessity Checklist

Your doctor's letter should address:

  • Specific diagnosis (wet AMD, diabetic macular edema, etc.)
  • Current disease activity based on imaging
  • Response to current treatment regimen
  • Why alternative treatments aren't appropriate
  • Treatment goals and monitoring plan

Timeline: Submission and Decision Windows

Step Timeline Action Required
Submit Renewal 30-45 days before expiration Ophthalmologist submits to CVS Caremark
Standard Decision 30-45 days after submission Aetna reviews and issues determination
Expedited Review 72 hours (if urgent) For cases with risk of vision loss
Appeal Deadline 180 days after denial Internal Aetna appeals process
External Review 120 days after final denial Smart NC external review

Important: Under proposed North Carolina legislation, insurers may soon be required to make prior authorization decisions within 48 hours of receiving complete information. This change is currently pending Senate approval.

If Authorization Lapses: Bridge Options

If your prior authorization expires before renewal approval, discuss these options with your ophthalmologist:

Temporary Alternatives

  • Bevacizumab (Avastin) - Often requires minimal or no prior authorization
  • Biosimilars (Byooviz, Cimerli) - May have less restrictive approval requirements
  • Emergency/Urgent Appeals - For cases where treatment delay risks vision loss

Immediate Actions

  1. Contact CVS Specialty Pharmacy at 1-888-877-0518 for status updates
  2. Request your doctor submit an urgent/expedited renewal request
  3. Ask about temporary coverage pending approval
  4. Consider formal appeals process if renewal is denied
From our advocates: We've seen cases where patients successfully maintained coverage during renewal delays by having their ophthalmologist document that treatment interruption could cause irreversible vision loss. This urgent medical necessity argument often expedites the review process.

2024 Annual Changes: What's New

North Carolina Medicaid Flexibilities

Through January 31, 2025, North Carolina Medicaid Tailored Plans have relaxed prior authorization requirements. This means:

  • Many pharmacy prior authorizations are temporarily waived
  • Retroactive authorization may be available for services provided during this period
  • Existing authorizations must be honored for their full duration

Formulary Updates

Aetna has made several changes to their 2024 formulary affecting retinal treatments:

  • Biosimilars preferred - Byooviz and Cimerli may be required before brand-name drugs
  • Step therapy requirements - May need to try preferred agents first
  • Tier changes - Some medications may have moved to higher cost-sharing tiers

What to Verify Annually

  • Current formulary status of your medication
  • Any new step therapy requirements
  • Changes to quantity limits or dosing restrictions
  • Updated prior authorization forms or requirements

Personal Tracker: Template for Progress

Use this template to track your renewal process:

Authorization Details:

  • Current authorization expires: ___________
  • Medication and strength: ___________
  • Prescribing physician: ___________
  • CVS Specialty Pharmacy: ___________

Renewal Timeline:

  • Renewal started (date): ___________
  • OCT imaging completed (date): ___________
  • Visual acuity tested (date): ___________
  • Renewal packet submitted (date): ___________
  • Decision received (date): ___________
  • New authorization number: ___________

If Denied:

  • Appeal submitted (date): ___________
  • External review requested (date): ___________

Counterforce Health helps patients and clinicians navigate complex prior authorization renewals by turning denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and creates point-by-point rebuttals aligned with each payer's specific requirements.

Appeals Process: Smart NC External Review

If Aetna denies your renewal request, North Carolina residents have strong appeal rights through the Smart NC program.

Internal Appeals with Aetna

  • First level: Submit within 180 days of denial
  • Timeline: 30-45 days for standard review, 72 hours for expedited
  • Required: Use Aetna's appeal forms and include additional clinical evidence

External Review through Smart NC

  • Eligibility: Must exhaust Aetna's internal appeals first
  • Deadline: Within 120 days of final internal denial
  • Timeline: 45 days for standard review, 72 hours for expedited
  • Cost: Free to consumers
  • Contact: 1-855-408-1212 or NC Department of Insurance

Success Rates

External reviews in North Carolina overturn insurance denials in approximately 20-50% of cases, with specialty drug denials often seeing success rates at the higher end when strong medical necessity is documented.

FAQ

How long does Aetna CVS Health prior authorization take in North Carolina? Standard renewals typically take 30-45 days. Expedited reviews for urgent cases are completed within 72 hours.

What if my doctor says Eylea or Lucentis is not on formulary? You can request a formulary exception with documentation of medical necessity. Aetna must provide at least 30 days' notice before removing a drug from formulary.

Can I get an expedited renewal if my authorization expires? Yes, if treatment delay would seriously jeopardize your health or vision. Your ophthalmologist must document the urgent medical need.

Do step therapy requirements apply to renewals? Generally no, if you're already established on therapy. However, 2024 formulary changes may require trying biosimilars before brand-name drugs for new patients.

What happens if Smart NC external review denies my appeal? The external review decision is binding on Aetna. However, you may explore manufacturer patient assistance programs or other funding options.

How do I know if my plan is eligible for Smart NC external review? Most fully insured plans are eligible. Self-funded employer plans may not be covered unless the employer opted into North Carolina's system.

Can I submit additional information during the external review? Yes, you have up to 7 days after your case is accepted to submit additional clinical documentation.

What should I do if I can't afford my medication during the appeals process? Contact the manufacturer's patient assistance program: Regeneron (Eylea) at 1-855-394-5632 or Genentech (Lucentis) at 1-866-422-2377.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances and plan details. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For additional help navigating North Carolina insurance appeals, contact Smart NC at 1-855-408-1212.

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