By Counterforce Health Team in Koselugo (selumetinib) —

Renewing Koselugo (Selumetinib) Coverage with Aetna CVS Health in Virginia: 2025 Requirements & Timeline

Answer Box: Renewing Koselugo Coverage with Aetna CVS Health in Virginia

To renew Koselugo (selumetinib) coverage with Aetna CVS Health in Virginia, submit your prior authorization renewal 2-4 weeks before your current approval expires. You'll need updated clinical documentation showing continued benefit, current LVEF monitoring results, ophthalmologic evaluations, and prescriber attestation. Submit through Aetna's provider portal or specialty pharmacy channels. If denied, Virginia residents have 120 days to file an external review with the State Corporation Commission Bureau of Insurance.

First step today: Contact your specialty pharmacy (CVS Specialty) to check your current approval expiration date and initiate the renewal process.

Table of Contents

  1. When to Start Your Renewal Process
  2. Required Documentation for Renewal
  3. Monitoring Requirements & Safety Updates
  4. How to Submit Your Renewal
  5. Timeline & Decision Windows
  6. If Your Coverage Lapses
  7. Annual Changes to Watch
  8. Appeals Process in Virginia
  9. Your Personal Renewal Tracker

When to Start Your Renewal Process

Most Koselugo prior authorizations with Aetna CVS Health are approved for 6-12 month periods. Don't wait until the last minute—coverage gaps can interrupt this critical therapy.

Renewal Triggers

Start your renewal process when you notice:

  • 2-4 weeks before expiration: Ideal timing to avoid gaps
  • Pharmacy notification: CVS Specialty will typically contact you 30 days before expiration
  • Dose changes: Any adjustment requires a new prior authorization
  • New side effects: Significant toxicity may trigger additional review
Tip: Set a calendar reminder 6 weeks before your approval expires. This gives you buffer time if additional documentation is needed.

Required Documentation for Renewal

Aetna CVS Health requires comprehensive documentation to prove continued medical necessity and appropriate monitoring for Koselugo renewals.

Core Requirements

Document Type What's Needed Source
Clinical Response Imaging showing tumor response or stabilization, symptom improvement documentation Aetna Medicaid Policy
Safety Monitoring Current LVEF results, ophthalmologic evaluation, adverse event log FDA Label Requirements
Prescriber Attestation Confirmed NF1 diagnosis, inoperable plexiform neurofibromas, continued benefit Aetna PA Requirements
Adherence Documentation Pharmacy fill history, missed dose explanations CVS Specialty records

Clinical Evidence Package

Your healthcare team should compile:

  1. Recent MRI with volumetric analysis showing:
    • Tumor size measurements compared to baseline
    • Percentage change in tumor volume
    • Radiologist's assessment of response or stability
  2. Symptom assessment documentation:
    • Pain scores or functional improvement measures
    • Quality of life assessments
    • Photographic documentation of visible improvements (if applicable)
  3. Treatment timeline summary:
    • Start date and initial tumor measurements
    • Previous imaging results showing progression or response
    • Any dose modifications and reasons

Monitoring Requirements & Safety Updates

Koselugo requires ongoing safety monitoring that must be documented for renewal approval.

Cardiac Monitoring Schedule

  • LVEF assessment every 3 months during the first year
  • Every 6 months thereafter via echocardiogram or cardiac MRI
  • If LVEF drops below normal or decreases ≥10% from baseline, more frequent monitoring is required

Ophthalmologic Evaluations

  • Regular eye exams every 3-6 months or more frequently if symptoms develop
  • Documentation of any retinal changes or visual symptoms
  • Optical coherence tomography (OCT) if retinal pigment epithelial detachment is suspected
Note: Missing or overdue monitoring results are common reasons for renewal denials. Keep appointments current and ensure results are sent to your prescribing physician promptly.

How to Submit Your Renewal

Submission Methods

Primary Option: Aetna Provider Portal

  • Fastest processing time
  • Real-time status updates
  • Electronic document upload

Alternative Options:

  • Availity platform for participating providers
  • CVS Specialty coordination (they can initiate on your behalf)
  • Fax submission (verify current fax number with Aetna)

Required Forms

Submit the complete prior authorization packet including:

  • Updated prior authorization form (specific to your Aetna plan)
  • Clinical documentation package
  • Signed prescriber attestation
  • Current insurance card copy
Tip: CVS Specialty can often handle the renewal submission process for you. Contact them at the number on your medication packaging to discuss coordination.

Timeline & Decision Windows

Standard Processing Times

  • Initial review: 7-14 business days
  • Additional information requests: Add 5-10 days
  • Final determination: Within 30 days of complete submission

Expedited Reviews

For urgent situations where therapy interruption could be harmful:

  • Request expedited review through your prescriber
  • Decision timeline: 72 hours for urgent requests
  • Documentation required: Physician attestation of medical urgency

If Your Coverage Lapses

Immediate Actions

  1. Contact CVS Specialty immediately to discuss temporary supply options
  2. Request expedited review if renewal is pending
  3. Explore manufacturer assistance through Koselugo patient support

Bridge Options to Discuss

  • Emergency supply: Some plans allow 30-day emergency fills
  • Temporary prior authorization: May be available while renewal is processed
  • Patient assistance programs: AstraZeneca may provide temporary access
Important: Never stop Koselugo abruptly without medical supervision. Work with your healthcare team to maintain continuity.

Annual Changes to Watch

2025 Formulary Status

Koselugo remains covered on Aetna's 2025 formularies with:

  • Specialty tier placement (highest cost-sharing)
  • Prior authorization required
  • Quantity limit: 240 units per fill
  • Specialty pharmacy requirement (CVS Specialty)

What to Verify Annually

  • Formulary tier changes affecting your copay
  • Prior authorization criteria updates
  • Specialty pharmacy network changes
  • Quantity limit modifications

Contact Aetna member services each January to confirm your specific plan's coverage details.

Appeals Process in Virginia

If your Koselugo renewal is denied, Virginia residents have strong appeal rights through the State Corporation Commission.

Internal Appeals with Aetna

  1. File within 180 days of denial notice
  2. Submit additional documentation addressing denial reasons
  3. Request peer-to-peer review with an oncology specialist
  4. Timeline: 30-45 days for standard appeals, 72 hours for expedited

Virginia External Review Process

After exhausting internal appeals:

  1. Eligibility: Must file within 120 days of final Aetna denial
  2. Submit Form 216-A to Virginia State Corporation Commission
  3. Required documents: Final denial letter, medical records, insurance card copy
  4. Timeline: 45 days for standard review, 72 hours for expedited

Submit to:

  • Email: [email protected]
  • Fax: (804) 371-9915
  • Mail: State Corporation Commission, Bureau of Insurance – External Review, P.O. Box 1157, Richmond, VA 23218
Virginia Advantage: Cancer treatment denials can proceed directly to external review without completing internal appeals first—a special provision recognizing the urgency of oncology care.

At Counterforce Health, we help patients and clinicians turn insurance denials into successful appeals by analyzing denial letters, identifying the specific coverage criteria, and drafting evidence-backed responses. Our platform pulls the right clinical citations and weaves them into compelling appeals that speak directly to payer policies and requirements.

Your Personal Renewal Tracker

Use this template to stay organized:

Key Dates

  • Current approval expires: ___________
  • Renewal submission target: ___________ (2-4 weeks before expiration)
  • Last LVEF assessment: ___________
  • Next eye exam due: ___________

Documentation Checklist

  • Recent MRI with volumetric analysis
  • LVEF results (within required timeframe)
  • Ophthalmologic evaluation
  • Symptom assessment documentation
  • Pharmacy fill history
  • Updated prior authorization form
  • Prescriber attestation signed

Contacts

  • CVS Specialty phone: ___________
  • Prescriber office: ___________
  • Aetna member services: ___________
  • Virginia Bureau of Insurance: (804) 371-9741

Response Documentation

  • Clinical response: Tumor volume change ____%
  • Symptom improvement: ___________
  • Adherence rate: ___________
  • Side effects: ___________

From Our Advocates

"We've seen families successfully maintain Koselugo coverage by staying ahead of renewal deadlines and keeping meticulous records of clinical response. One key tip: always request copies of imaging reports and keep a simple log of symptom changes between visits. When renewal time comes, this documentation package makes the difference between a smooth approval and a lengthy appeal process."

FAQ: Koselugo Renewals with Aetna CVS Health

How long does Aetna prior authorization renewal take? Standard renewals take 7-14 business days, with up to 30 days if additional information is requested. Submit 2-4 weeks before expiration to avoid gaps.

What if my tumor hasn't shrunk but symptoms improved? Document functional improvements, pain reduction, or quality of life benefits. Stable disease with symptom relief often qualifies for continued coverage.

Can I switch from CVS Specialty to another pharmacy? No, Koselugo requires specialty pharmacy dispensing, and Aetna contracts primarily with CVS Specialty for this medication.

What happens if I miss monitoring appointments? Overdue LVEF or eye exams are common denial reasons. Reschedule immediately and ensure results reach your prescriber before renewal submission.

Is step therapy required for Koselugo renewals? No, step therapy typically applies only to initial approvals. Renewals focus on continued benefit and appropriate monitoring.

Can I appeal if my renewal is denied for cost reasons? Yes, but cost alone isn't grounds for external review in Virginia. Focus on medical necessity arguments and ensure all clinical criteria are met.

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 details. For official Virginia insurance regulations and appeal rights, visit the State Corporation Commission Bureau of Insurance.

The appeals process and external review options described here can help Virginia residents navigate coverage challenges, but individual circumstances vary. When facing complex denials, consider consulting with Counterforce Health or other patient advocacy resources to strengthen your appeal strategy.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.