By Counterforce Health Team in Venclexta (venetoclax) —

The Requirements Checklist to Get Venclexta (venetoclax) Covered by Aetna (CVS Health) in Pennsylvania

Answer Box: Getting Venclexta (venetoclax) Covered by Aetna (CVS Health) in Pennsylvania

Aetna (CVS Health) requires prior authorization for Venclexta with documented BTK inhibitor failure for CLL/SLL and combination therapy for AML. Submit PA through CVS Caremark portal with complete TLS prevention plan, diagnosis confirmation, and prior therapy records. Standard approval takes 5-15 business days; expedited reviews complete within 72 hours. Pennsylvania's new external review program overturns about 50% of denials after internal appeals. First step today: Contact CVS Specialty Pharmacy at 1-800-237-2767 to start the PA process and verify current requirements.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding and Billing Documentation
  5. Documentation Packet Essentials
  6. Submission Process and Forms
  7. CVS Specialty Pharmacy Requirements
  8. After Submission: Tracking and Follow-up
  9. Common Denial Prevention Tips
  10. Appeals Process in Pennsylvania
  11. Printable Checklist Summary

Who Should Use This Checklist

This checklist is designed for Pennsylvania patients with chronic lymphocytic leukemia (CLL), small lymphocytic lymphoma (SLL), or acute myeloid leukemia (AML) who need Venclexta (venetoclax) covered by Aetna (CVS Health) plans. It's also valuable for oncologists, specialty pharmacies, and patient advocates navigating the prior authorization process.

Expected outcome: With complete documentation following this checklist, most PA requests receive approval within 5-15 business days. Incomplete submissions are the leading cause of denials, which this systematic approach helps prevent.

Member & Plan Basics

Coverage Verification Requirements

Before starting your PA request, confirm these essential details:

  • Active Aetna coverage: Verify your policy is current and covers specialty medications
  • Plan type: Commercial, Medicare Advantage, or Medicaid (Aetna Better Health Pennsylvania)
  • Specialty pharmacy requirement: Venclexta must be dispensed through CVS Specialty Pharmacy
  • Prior authorization status: All Aetna plans require PA for venetoclax
Tip: Call Aetna member services at 1-800-872-3862 to verify your specific plan's formulary status and any updated requirements.

Deductible and Cost-Sharing

Plan Type Typical Tier Monthly Cost Range
Commercial Specialty Tier 4 $150-400+ copay
Medicare Advantage Tier 5 25-33% coinsurance
Medicaid Covered $0-3 copay

Source: Aetna formulary documents

Clinical Criteria Requirements

For CLL/SLL Patients

Aetna requires documentation of these clinical criteria:

Diagnosis Confirmation:

  • Flow cytometry showing CD19+/CD20+/CD23+/CD5+ B-cells
  • ICD-10 code C91.10 (CLL, not in remission) or C91.11 (in remission)
  • Pathology report within last 2 years
  • Cytogenetics results (del(17p)/TP53 status recommended)

Step Therapy Requirement:

  • Prior BTK inhibitor trial and failure/intolerance
  • Document specific agent (ibrutinib, acalabrutinib, or zanubrutinib)
  • Include dates, doses, and reasons for discontinuation
  • Progression notes or toxicity reports

For AML Patients

Diagnosis Requirements:

  • Newly diagnosed AML with ICD-10 code C92.00 (not in remission)
  • Molecular/cytogenetic testing (FLT3, IDH1/2, NPM1)
  • Age ≥75 years OR chemotherapy-ineligible due to comorbidities

Treatment Plan:

  • Combination with azacitidine, decitabine, or low-dose cytarabine
  • No prior intensive chemotherapy for newly diagnosed patients

Coding and Billing Documentation

ICD-10 Codes for Venclexta

Condition Primary Code Description
CLL C91.10 Chronic lymphocytic leukemia, not in remission
CLL C91.11 Chronic lymphocytic leukemia, in remission
SLL C83.00-C83.09 Small cell B-cell lymphoma (various sites)
AML C92.00 Acute myeloblastic leukemia, not in remission
AML C92.01 Acute myeloblastic leukemia, in remission

NDC Codes and Packaging

Key NDC Codes (use 11-digit format):

  • Starting pack: 00074-0579-28
  • 10 mg tablets: 00074-0561-14 (wallet pack)
  • 50 mg tablets: 00074-0566-07 (wallet pack)
  • 100 mg tablets: 00074-0576-22 (120-tablet bottle)

Source: Genentech billing and coding guide

Documentation Packet Essentials

Medical Necessity Letter Components

Your oncologist's letter must include:

  1. Patient identification: Full name, DOB, policy number, diagnosis with ICD-10
  2. Clinical rationale: Why venetoclax is medically necessary for this patient
  3. Prior therapy history: Specific agents tried, dates, outcomes, reasons for failure
  4. Treatment goals: Expected outcomes and monitoring plan
  5. Guideline support: NCCN references and FDA labeling citations
  6. TLS prevention plan: Risk assessment and monitoring protocol

Required Attachments

  • Pathology/flow cytometry reports confirming diagnosis
  • Prior therapy documentation (prescription records, progress notes)
  • Baseline laboratory results (CBC, comprehensive metabolic panel, LDH, uric acid)
  • Performance status assessment for oral therapy tolerance
  • Prescriber NPI and contact information
Note: Incomplete TLS (tumor lysis syndrome) prevention plans are a leading cause of denials. Include detailed risk stratification and monitoring schedule.

Submission Process and Forms

CVS Caremark Prior Authorization

How to obtain PA forms:

  • CVS Caremark provider portal (preferred method)
  • Call 1-800-294-5979 for current forms
  • Fax requests to 1-855-633-7673 (verify current fax number)

Submission methods:

  1. Online: CVS Caremark provider portal with complete documentation
  2. Fax: 1-855-633-7673 with all required attachments
  3. Phone support: 1-800-294-5979 for assistance

Timeline Expectations

Review Type Timeline When to Use
Standard 5-15 business days Most requests
Expedited 72 hours Urgent medical need with physician letter
Peer-to-peer 24-48 hours to schedule After initial denial

Source: CVS Caremark PA process

CVS Specialty Pharmacy Requirements

Venclexta must be dispensed through CVS Specialty Pharmacy for Aetna coverage. Here's how to set this up:

Enrollment Process

  1. Prescription transfer: Have your oncologist send the prescription directly to CVS Specialty
  2. Patient enrollment: Call 1-800-237-2767 to complete enrollment
  3. Insurance verification: CVS Specialty will verify coverage and assist with PA if needed
  4. Delivery setup: Arrange home delivery or pickup preferences

CVS Specialty Contact Information

  • Phone: 1-800-237-2767
  • Website: cvsspecialty.com
  • Services: PA assistance, insurance verification, patient education, adherence support

Counterforce Health helps patients navigate complex specialty pharmacy requirements and can assist with documentation if your initial PA is denied.

After Submission: Tracking and Follow-up

Monitoring Your PA Status

Track your request through:

  • CVS Caremark member portal
  • Phone: 1-800-237-2767 (CVS Specialty)
  • Confirmation number from initial submission

What to record:

  • PA reference number
  • Submission date and method
  • Required documents submitted
  • Follow-up dates and contacts

Response Timeline

Most PA decisions arrive within 5-15 business days. If you haven't heard back within this timeframe, call CVS Specialty to check status and submit any additional requested information within 48 hours.

Common Denial Prevention Tips

Five Critical Pitfalls to Avoid

  1. Incomplete TLS prevention plan: Always include detailed risk assessment, ramp-up schedule, and monitoring labs
  2. Missing step therapy documentation: For CLL, provide clear evidence of BTK inhibitor failure with dates and reasons
  3. Inadequate prior authorization form: Use current Aetna-specific forms, not generic templates
  4. Wrong pharmacy designation: Specify CVS Specialty Pharmacy in all submissions
  5. Insufficient clinical rationale: Include NCCN guideline citations and specific medical necessity justification

Documentation Best Practices

From our advocates: "We've seen PA approvals increase significantly when oncologists include specific NCCN guideline page numbers and FDA labeling sections in their medical necessity letters. This level of detail demonstrates thorough clinical review and often prevents the need for peer-to-peer discussions."

Appeals Process in Pennsylvania

If your initial PA is denied, Pennsylvania offers strong appeal rights with recent improvements to the external review process.

Internal Appeal (Required First Step)

Deadline: 180 calendar days from denial notice How to file:

  • Use Aetna Provider Complaint and Appeal Request form
  • Submit via Availity provider portal or fax
  • Include denial letter and new supporting evidence

Timeline: 30-45 business days standard; 72 hours expedited with physician urgency letter

Pennsylvania External Review

Pennsylvania launched its Independent External Review Program in January 2024, with impressive results for patients.

Key statistics: About 50% of external appeals are overturned in favor of patients, requiring insurers to cover previously denied treatments.

Process:

  1. Deadline: 4 months after final internal denial
  2. How to file: Online at pa.gov external review portal
  3. Timeline: 45 days for standard review; 72 hours for expedited
  4. Cost: No fee for patients
  5. Decision: Binding on Aetna if approved

When External Review Is Most Effective

External review works best for denials based on:

  • Medical necessity disputes
  • Inappropriate step therapy requirements
  • "Experimental" determinations for FDA-approved uses
  • Quantity limit restrictions that don't align with prescribing information

Pennsylvania's external review program has shown particular success with specialty cancer medications where clinical evidence supports use.

Source: Pennsylvania Insurance Department External Review Program

Printable Checklist Summary

Before Submitting PA

  • Active Aetna coverage verified
  • CVS Specialty Pharmacy enrollment initiated
  • Current PA form obtained (call 1-800-294-5979)
  • ICD-10 diagnosis code confirmed
  • Step therapy documentation complete (CLL patients)
  • TLS prevention plan detailed
  • Medical necessity letter with NCCN citations
  • All required attachments gathered

Documentation Packet

  • Pathology/flow cytometry reports
  • Prior therapy records with dates and outcomes
  • Baseline laboratory results
  • Prescriber NPI and contact information
  • Patient insurance information and policy number

After Submission

  • PA reference number recorded
  • Follow-up date scheduled (10 business days)
  • CVS Specialty contact established
  • Appeal timeline noted (180 days if denied)

Need additional support? Counterforce Health specializes in turning insurance denials into successful appeals by creating targeted, evidence-backed documentation that aligns with payer-specific requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for the most current requirements. Coverage policies may vary by plan type and individual circumstances.

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