By Counterforce Health Team in Arcalyst (rilonacept) —

Resources to Get Arcalyst (rilonacept) Approved by Aetna (CVS Health) in Illinois: Complete Forms, Appeals, and Support Directory

Answer Box: Getting Arcalyst (rilonacept) Covered by Aetna (CVS Health) in Illinois

Arcalyst requires prior authorization through Aetna's specialty pharmacy channels. Submit the PA form via Availity portal or fax to 1-888-267-3277 (commercial) with diagnosis confirmation, specialist consultation, and prior therapy documentation. If denied, file an internal appeal within 180 days, then request Illinois Department of Insurance external review within 4 months. Contact Aetna member services at the number on your ID card for coverage verification and case management support.

Table of Contents

  1. Start Here: Verify Your Plan and Find the Right Resources
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Online Systems
  4. Fax Numbers and Mailing Addresses
  5. Specialty Pharmacy Requirements
  6. Member Services and Provider Support Lines
  7. Illinois Appeals and External Review Process
  8. When to Update Your Resources

Start Here: Verify Your Plan and Find the Right Resources

Before diving into forms and phone numbers, confirm which Aetna plan you have. Your member ID card will show one of these:

  • Aetna Commercial Plans (employer-sponsored)
  • Aetna Better Health Illinois (Medicaid)
  • Aetna Better Health Premier Plan MMAI (Medicare-Medicaid dual eligible)
  • Illinois State Employee Group Insurance Program (SEGIP)

Each plan type has different forms, submission addresses, and contact numbers. The resources below are organized by plan type where they differ.

Tip: Call the member services number on your ID card first to verify Arcalyst coverage and get plan-specific guidance before starting the prior authorization process.

Prior Authorization Forms and Requirements

Current Forms (2025)

For Aetna Commercial Plans:

For Aetna Medicare Plans:

  • Same form as above
  • Submit to fax: 1-855-799-2554
  • Same mailing address

Required Documentation Checklist

✅ Confirmed diagnosis with ICD-10 codes:

  • CAPS (Cryopyrin-Associated Periodic Syndromes)
  • DIRA (Deficiency of Interleukin-1 Receptor Antagonist)
  • Recurrent pericarditis

✅ Specialist consultation documentation (rheumatologist, immunologist, or cardiologist)

✅ Prior therapy records showing trials and outcomes of:

  • NSAIDs and colchicine (for pericarditis)
  • Corticosteroids (if applicable)
  • Other standard treatments per condition

✅ Clinical notes supporting medical necessity

✅ Patient age and weight (FDA labeling requirements)

Note: Submit precertification at least two weeks before anticipated start of therapy to avoid delays.

Submission Portals and Online Systems

Primary Online Submission

Availity Provider Portal

  • Website: Availity.com
  • Most Aetna specialty drug PA requests
  • Requires provider registration and Aetna contracting

NovoLogix (within Availity)

  • For certain specialty medications
  • Integrated with Availity system
  • Check current drug list for Arcalyst requirements

CVS Caremark Provider Portal

For plans where CVS Caremark manages pharmacy benefits:

  • Access through CVS Caremark provider website
  • May require separate registration
  • Confirm with Aetna member services which portal to use
Tip: Upload all supporting documentation (lab results, clinic notes, prior therapy records) directly to the portal to expedite review.

Fax Numbers and Mailing Addresses

Aetna Direct Submission

Plan Type Fax Number Mailing Address
Commercial 1-888-267-3277 Aetna Pharmacy Management
PO Box 14579
Lexington, KY 40512
Medicare 1-855-799-2554 Same as above
Medicaid Contact plan directly (verify with member services)

CVS Caremark Submission

Fax: 1-888-487-9257 (verify on current PA form) Mail: CVS Caremark, P.O. Box 52025, Phoenix, AZ 85072-2025

Cover Sheet Best Practices

  • Include patient name, member ID, and date of birth
  • Mark "URGENT" if expedited review needed
  • List total number of pages being faxed
  • Include provider contact information for questions

Specialty Pharmacy Requirements

Arcalyst must be dispensed through an Aetna-designated specialty pharmacy. Retail pharmacies cannot fill this medication.

Specialty Pharmacy Onboarding Steps

  1. Obtain PA approval first (required before specialty pharmacy enrollment)
  2. Contact Aetna Specialty Pharmacy at the number provided in your approval letter
  3. Complete patient enrollment forms and consent documents
  4. Coordinate delivery scheduling and storage requirements
  5. Set up injection training if needed

Transfer from Another Specialty Pharmacy

If transferring from a different specialty pharmacy:

  • Request prescription transfer through Aetna's designated specialty pharmacy
  • Provide previous pharmacy contact information
  • Ensure no gaps in therapy during transfer process

Member Services and Provider Support Lines

Illinois-Specific Contact Numbers

Plan Type Phone Number Hours TTY
Illinois State Employee Plan 1-855-339-9731 Mon–Fri, 7 AM–5 PM CT 711
Aetna Better Health (Medicaid) 1-866-329-4701 Mon–Fri, 8:30 AM–5 PM 711
MMAI Dual Plans 1-866-600-2139 24/7 711

What to Ask When You Call

For Coverage Verification:

  • "Is Arcalyst covered under my plan?"
  • "What tier is Arcalyst on my formulary?"
  • "What's my specialty drug copay or coinsurance?"

For Prior Authorization Support:

  • "What specific documentation is needed for Arcalyst PA?"
  • "Can you check the status of my submitted PA?"
  • "Is there a case manager who can help with this specialty drug?"

For Appeals Assistance:

  • "How do I file an internal appeal for a denied PA?"
  • "What's the deadline for my appeal?"
  • "Can you expedite this appeal due to medical urgency?"

Provider Support

Aetna Provider Services:

  • Commercial: 1-888-632-3862
  • Medicare: 1-800-624-0756

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform helps identify denial reasons and drafts point-by-point rebuttals aligned with payer policies, pulling the right clinical evidence and meeting procedural requirements for coverage determinations and appeals.

Illinois Appeals and External Review Process

Internal Appeals with Aetna

Timeline: File within 180 days of denial notice (commercial plans)

Required Documents:

  • Completed appeal form (provided with denial letter)
  • Medical necessity statement from prescriber
  • Supporting medical records
  • Documentation of prior therapy failures

Illinois External Review Process

If your internal appeal is denied, Illinois residents have the right to an independent external review through the Illinois Department of Insurance.

Key Deadlines:

  • Request external review within 4 months of final adverse determination
  • Standard review decision within 45 days
  • Expedited review within 24 hours to 5 days for urgent cases

How to File:

  1. Obtain the Request for External Review form from IDOI
  2. Complete form with supporting documentation
  3. Submit to: Illinois Department of Insurance, Office of Consumer Health Information, 320 W. Washington St., 4th Floor, Springfield, IL 62767
  4. Or fax to: 1-217-557-8495

Illinois Consumer Assistance

Illinois Department of Insurance Consumer Assistance:

  • Phone: 1-877-850-4740
  • Helps with appeals and external review questions

Illinois Attorney General Health Care Helpline:

  • Phone: 1-877-305-5145
  • Can intervene informally with insurers
From Our Advocates: We've seen cases where patients initially denied for Arcalyst were approved on appeal when their specialist provided detailed documentation of inflammatory markers and prior treatment failures. The key is comprehensive clinical documentation that directly addresses the payer's specific denial reasons.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before dispensing Aetna PA form Aetna Policy
Specialist Requirement Must be prescribed by/with specialist PA form clinical criteria FDA Labeling
Specialty Pharmacy Only Cannot fill at retail pharmacy Aetna member services Plan Documents
Step Therapy May require trial of other medications first Plan formulary CVS Caremark
Appeals Deadline 180 days for commercial, varies by plan Denial letter instructions Plan Terms

When to Update Your Resources

Insurance policies, forms, and contact information change regularly. Update your resources:

Quarterly:

  • Check for new PA form versions on Aetna's website
  • Verify current fax numbers and addresses
  • Review formulary status changes

Annually:

  • Confirm specialty pharmacy network
  • Review plan benefits and coverage criteria
  • Check Illinois Department of Insurance contact information

Before Each Submission:

  • Download the most current PA form
  • Verify submission fax number on the form itself
  • Confirm member services phone number on patient's ID card

Frequently Asked Questions

How long does Aetna prior authorization take for Arcalyst in Illinois? Standard PA decisions typically take 72 hours for Medicare plans and up to 15 business days for commercial plans. Expedited requests can be decided within 24 hours if medical urgency is documented.

What if Arcalyst is not on my Aetna formulary? Request a formulary exception through the appeals process. Provide medical necessity documentation and evidence that formulary alternatives are inappropriate or have failed.

Can I request an expedited appeal if my Arcalyst is denied? Yes, if a delay would seriously jeopardize your health. Contact Aetna member services immediately and request expedited review with supporting medical documentation.

Does Illinois have special protections for specialty drug appeals? Illinois provides external review rights through the Department of Insurance, with binding decisions from independent physician reviewers. The state also has strict timelines for insurer appeal responses.

Sources & Further Reading

For complex cases requiring detailed appeal strategy and evidence compilation, Counterforce Health provides specialized support in turning insurance denials into successful appeals through targeted, evidence-backed submissions that meet payer-specific requirements.

This guide is for informational purposes only and does not constitute medical or legal advice. Insurance policies and procedures may change. Always verify current requirements with your insurer and consult healthcare professionals for medical decisions. For additional assistance with Illinois insurance matters, contact the Illinois Department of Insurance at 1-877-850-4740.

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