By Counterforce Health Team in Bavencio (avelumab) —

The Requirements Checklist to Get Bavencio (avelumab) Covered by Aetna (CVS Health) in Illinois

Answer Box: Get Bavencio (avelumab) Covered by Aetna (CVS Health) in Illinois

Fastest Path to Approval: Submit prior authorization with complete pathology reports, platinum chemotherapy history, and staging documentation. For Merkel cell carcinoma, provide metastatic disease confirmation. For urothelial carcinoma, document stable disease after platinum therapy within 4-10 weeks. First step today: Download Aetna's Bavencio PA form and gather required clinical records. Illinois residents have 180 days to appeal denials, followed by binding external review within 4 months.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Documentation
  5. Submission Process
  6. CVS Specialty Pharmacy Setup
  7. After Submission: Tracking & Follow-up
  8. Common Denial Reasons & Prevention
  9. Illinois Appeals Process
  10. Printable Checklist

Who Should Use This Checklist

This checklist is designed for patients, caregivers, and healthcare providers seeking Bavencio (avelumab) coverage through Aetna (CVS Health) plans in Illinois. Use this guide if you're dealing with:

  • Metastatic Merkel cell carcinoma requiring first-line treatment
  • Locally advanced or metastatic urothelial carcinoma for maintenance therapy after platinum chemotherapy
  • Initial prior authorization submissions or appeal preparations
  • Transfer from another specialty pharmacy to CVS Specialty

Expected Outcome: Following this checklist increases approval likelihood by ensuring complete documentation meets Aetna's published criteria and Illinois regulatory requirements.

Member & Plan Basics

Coverage Verification Requirements

Before starting, confirm:

  • ✅ Active Aetna (CVS Health) coverage with pharmacy benefits
  • ✅ Plan type: Commercial, Medicare Advantage, or Medicaid managed care
  • ✅ Deductible status and specialty tier copayment amounts
  • ✅ In-network oncology provider status
Tip: Call the member services number on your insurance card to verify specialty drug coverage and current deductible amounts.

Authorization Requirements:

  • Prior authorization is required for all Bavencio indications per Aetna's 2024 Precertification List
  • Initial approval typically covers 6 months
  • Renewals require response documentation and ongoing medical necessity

Clinical Criteria Requirements

FDA-Approved Indications

Merkel Cell Carcinoma:

  • Adults and pediatric patients ≥12 years
  • Metastatic disease confirmed by imaging
  • No prior systemic therapy required
  • ECOG performance status 0-2

Urothelial Carcinoma:

  • Locally advanced or metastatic disease
  • Maintenance setting only - after first-line platinum chemotherapy
  • Stable disease or response to platinum therapy
  • Treatment must begin within 4-10 weeks of last platinum dose

Required Clinical Documentation

For All Indications:

  • ✅ Pathology report confirming diagnosis
  • ✅ Current staging with imaging reports (CT, MRI, or PET)
  • ✅ ECOG performance status documentation
  • ✅ Complete blood count and comprehensive metabolic panel
  • ✅ Liver function tests

Additional for Urothelial Carcinoma:

  • ✅ Platinum chemotherapy records (agent, dates, cycle count)
  • ✅ Response assessment imaging after platinum therapy
  • ✅ Documentation of stable disease or response (no progression)
Clinician Corner: The medical necessity letter should explicitly state compliance with FDA labeling and include specific imaging dates showing disease status. Reference NCCN guidelines where applicable and document any contraindications to alternative therapies.

Coding & Documentation

Billing Codes

Code Type Code Description
HCPCS J-Code J9023 Injection, avelumab, 10 mg
ICD-10 (MCC) C4A.0-C4A.9 Merkel cell carcinoma by site
ICD-10 (MCC Metastatic) C7B.1 Secondary Merkel cell carcinoma
ICD-10 (Urothelial) C67.0-C67.9 Malignant neoplasm of bladder

Dosing Information:

  • Standard dose: 800 mg IV every 2 weeks (80 units of J9023)
  • Weight-independent flat dosing per FDA label
  • Infusion over 60 minutes with premedication protocols

Documentation Packet Components

Provider Note Elements:

  1. Detailed diagnosis with histologic confirmation
  2. Disease staging and extent of metastases
  3. Prior treatment history and response/failure documentation
  4. Current performance status and laboratory values
  5. Treatment plan rationale and expected monitoring

Letter of Medical Necessity Components:

  1. Patient demographics and insurance information
  2. Specific FDA indication being treated
  3. Clinical rationale with guideline support
  4. Prior therapy documentation (especially platinum for UC)
  5. Contraindications to alternative treatments
  6. Dosing schedule and duration of treatment

Submission Process

Step-by-Step Submission

1. Download Current Forms

2. Complete Required Sections

  • Patient demographics and insurance details
  • Prescriber information with NPI number
  • Clinical indication and supporting documentation
  • Dosing and administration plan

3. Submit via Preferred Method

  • Aetna Provider Portal (fastest processing)
  • Fax: (888) 267-3277
  • Phone: (866) 752-7021 for urgent cases

4. Confirm Receipt

  • Request confirmation number
  • Document submission date and method
  • Set follow-up reminder for 5-7 business days
Note: Incomplete submissions are the leading cause of delays. Double-check all required fields before submitting.

CVS Specialty Pharmacy Setup

Enrollment Process

Required Steps:

  1. Complete CVS Specialty Oncology Enrollment Form
  2. Provide insurance authorization approval
  3. Coordinate delivery to infusion site
  4. Set up patient support services

Submission Methods:

Transfer from Another Pharmacy

If transferring active therapy:

  • ✅ Request prescription transfer authorization
  • ✅ Provide current treatment response documentation
  • ✅ Coordinate timing to avoid treatment delays
  • ✅ Update insurance with new pharmacy information

After Submission: Tracking & Follow-up

Status Check Schedule

Timeline Expectations:

  • Initial review: 5-7 business days
  • Complete determination: 15 business days for standard requests
  • Expedited requests: 24-48 hours (urgent medical need)

What to Record:

  • ✅ Confirmation/reference numbers
  • ✅ Submission date and method
  • ✅ Contact person names and direct numbers
  • ✅ Follow-up appointment dates
  • ✅ Any additional information requests

Status Check Methods:

  • Aetna provider portal case tracking
  • Member services: number on insurance card
  • CVS Specialty coordination team

Common Denial Reasons & Prevention

Denial Reason Prevention Strategy Required Documentation
Incomplete clinical records Submit comprehensive packet All staging, labs, pathology reports
Missing platinum history (UC) Document all prior chemotherapy Treatment dates, agents, response assessment
Non-formulary status Request formulary exception Medical necessity letter with alternatives contraindicated
Step therapy not met Document failures/intolerances Prior treatment records with outcomes
Experimental/investigational Emphasize FDA approval FDA labeling, NCCN guideline references

Five Critical Pitfalls to Avoid

  1. Submitting outdated forms - Always use current year versions
  2. Missing signature requirements - Prescriber must sign; stamps not accepted
  3. Incomplete platinum documentation - For UC, provide complete chemotherapy records
  4. Vague medical necessity - Be specific about why alternatives aren't suitable
  5. Late renewal requests - Submit 30-45 days before expiration

Illinois Appeals Process

Internal Appeal Timeline

Filing Deadline: 180 calendar days from denial notice Decision Timeline: 15 business days (24-48 hours for expedited)

Required Documentation:

  • Original denial letter
  • Complete medical records
  • Updated physician statement
  • Any new supporting evidence

External Review Process

If internal appeal fails, Illinois residents can request binding external review:

Filing Deadline: 4 months from final internal denial Decision Timeline: 30 days standard, 72 hours expedited Cost: Free to consumers

How to File:

  1. Download forms from Illinois Department of Insurance
  2. Include all medical records and appeal history
  3. Submit within deadline - Illinois has shorter timeframe than many states

State Resources:

  • Illinois Department of Insurance: (877) 527-9431
  • Illinois Attorney General Health Care Bureau: (877) 305-5145
From Our Advocates: "We've seen Illinois external reviews succeed when the initial appeal included comprehensive imaging showing disease progression and detailed documentation of platinum therapy failures. The key is presenting a clear timeline that matches FDA indication 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 plan policies to create point-by-point rebuttals using the right clinical evidence and payer-specific workflows. Learn more about our prior authorization support.

Printable Checklist

Pre-Submission Checklist

Patient Information:

  • Active Aetna (CVS Health) coverage verified
  • Insurance card and policy details copied
  • Emergency contact information updated

Clinical Documentation:

  • Pathology report confirming diagnosis
  • Current staging with imaging dates
  • ECOG performance status documented
  • Laboratory results (CBC, CMP, LFTs)
  • Prior treatment history (especially platinum for UC)

Forms and Submission:

  • Current Aetna Bavencio PA form completed
  • Prescriber signature obtained (not stamped)
  • Medical necessity letter attached
  • Submission method selected (portal preferred)
  • Confirmation number received and recorded

Follow-up Planning:

  • Status check scheduled for 5-7 days
  • CVS Specialty enrollment initiated
  • Appeal strategy prepared if needed
  • Illinois external review timeline noted

Renewal Checklist

Response Documentation:

  • Recent imaging showing treatment response
  • Tolerability assessment
  • Ongoing medical necessity justification
  • Performance status update

Administrative:

  • Renewal request submitted 30-45 days early
  • Insurance coverage verified for new period
  • CVS Specialty coordination confirmed

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage processes and should not be considered medical advice. Coverage decisions depend on individual medical circumstances and specific insurance plan terms. For personalized guidance, consult with your healthcare provider and insurance representative. Illinois residents should verify current appeal deadlines and requirements with the Illinois Department of Insurance.

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