By Counterforce Health Team in Alecensa (alectinib) —

Do You Qualify for Alecensa (alectinib) Coverage by Blue Cross Blue Shield in Michigan? Decision Tree & Next Steps

Answer Box: Qualifying for Alecensa Coverage in Michigan

Yes, you likely qualify if you have ALK-positive non-small cell lung cancer confirmed by molecular testing. Blue Cross Blue Shield of Michigan requires prior authorization through their OncoHealth portal. First step today: Have your oncologist gather ALK test results, staging documentation, and treatment history, then submit via the OncoHealth OneUM™ portal. Standard approval takes up to 14 business days. If denied, you have 127 days to file an external review with Michigan DIFS.

Table of Contents

How to Use This Guide

This decision tree helps Michigan patients and their doctors determine if Alecensa (alectinib) will be covered by Blue Cross Blue Shield of Michigan (BCBSM). Work through each section based on your current situation—whether you're just starting the process, have received a denial, or need to gather additional documentation.

Note: This guide focuses on BCBSM commercial plans. Medicare and Medicaid coverage may have different requirements.

Eligibility Decision Tree

Step 1: Do you have confirmed ALK-positive NSCLC?

✅ YES → Continue to Step 2
❓ UNSURE → You need molecular testing first. Ask your oncologist about ALK testing via IHC or FISH.
❌ NO → Alecensa is not indicated for ALK-negative disease. Discuss other treatment options with your oncologist.

Step 2: What's your disease stage?

Metastatic (Stage IV) → You're Likely Eligible
Stage IIIA with complete surgical resection → You're Likely Eligible (adjuvant indication)
Earlier stage without surgery → You're Possibly Eligible (may need exception request)

Step 3: Are you working with an oncology specialist?

✅ YES → Continue with your current path
❌ NO → BCBSM requires oncology specialist involvement. Get a referral before proceeding.

If You're "Likely Eligible"

You meet the standard criteria for Alecensa coverage. Here's your action plan:

Document Checklist

Your oncologist needs to gather:

  • ALK-positive test results (laboratory report with IHC or FISH confirmation)
  • Staging documentation (imaging reports showing metastatic disease or surgical pathology for stage IIIA)
  • Oncology consultation notes (confirming NSCLC diagnosis and treatment plan)
  • Treatment history (prior chemotherapy records if applying for adjuvant use)
  • Prescription details (600 mg twice daily with food, standard dosing)

Submission Path

  1. Provider submits via OncoHealth OneUM™ portal (accessed through BCBSM's Availity portal)
  2. Alternative submission methods:
    • Phone: 1-888-916-2616
    • Fax: 1-800-264-6128
    • Mail: OncoHealth, 7000 Central Parkway, Ste 1750, Atlanta, GA 30328

Expected Timeline

  • Standard review: Up to 14 business days
  • Expedited review: 72 hours (requires urgent medical need documentation)

If You're "Possibly Eligible"

You may qualify but need additional documentation or testing:

Tests to Request

  • Complete staging workup if not already done
  • Molecular testing panel to confirm ALK status
  • Performance status assessment (ECOG or Karnofsky score)

What to Track

  • Document any symptoms or disease progression
  • Keep records of current treatments and responses
  • Note any contraindications to standard ALK inhibitors

Timeline to Re-apply

Once you have complete documentation, resubmit within 30 days. Most "possibly eligible" cases become approved with proper documentation.

If You're "Not Yet Eligible"

You don't currently meet standard criteria, but options exist:

Alternatives to Discuss

  • Other ALK inhibitors (crizotinib, brigatinib, lorlatinib)
  • Clinical trials for ALK-positive NSCLC
  • Compassionate use programs through Genentech

Prepare for Exception Requests

Work with your oncologist to document:

  • Why standard treatments aren't appropriate
  • Contraindications to formulary alternatives
  • Clinical evidence supporting Alecensa use

If You've Been Denied

Follow Michigan's structured appeals process:

Level 1: Internal Appeal with BCBSM

  • Deadline: 180 days from denial notice
  • How to file: Call member services or submit written appeal
  • Timeline: 30 days for standard review, 72 hours for urgent

Level 2: External Review with Michigan DIFS

From our advocates: "We've seen several Michigan DIFS reversals for specialty oncology drugs when the clinical documentation clearly showed medical necessity. The key is submitting complete pathology reports and evidence that formulary alternatives were tried or contraindicated."

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before coverage OncoHealth portal BCBSM Formulary
ALK Testing Must be positive by IHC/FISH Lab reports FDA labeling requirement
Specialist Involvement Oncologist must prescribe Consultation notes BCBSM policy
Age Requirement ≥18 years for standard NSCLC Medical records Standard coverage criteria
Dosing Limits 1,200 mg/day maximum Prescription Clinical guidelines

Appeals Playbook for Michigan

Internal Appeal Process

Who can file: Patient, provider, or authorized representative
Required documents:

  • Copy of denial letter
  • Medical records supporting necessity
  • Provider statement of medical necessity

Contact information:

  • Phone: Number on member ID card
  • Mail: Address provided in denial letter

External Review with DIFS

Eligibility: Must complete internal appeals first
Required forms: Health Care Request for External Review
Contact: 877-999-6442 (Monday-Friday, 8 a.m. to 5 p.m.)

Expedited review criteria:

  • Serious jeopardy to health
  • Urgently needed treatment
  • Doctor certification of urgency required

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documents
Missing ALK test Submit molecular testing results Lab report with ALK-positive confirmation
Step therapy not completed Document contraindications to alternatives Medical records showing intolerability
Not medically necessary Provide clinical evidence Oncologist letter with guideline citations
Dosing exceeds limits Justify higher dose Literature supporting dose escalation

FAQ

Q: How long does BCBSM prior authorization take in Michigan?
A: Standard review takes up to 14 business days through OncoHealth. Expedited reviews are completed within 72 hours for urgent cases.

Q: What if Alecensa is non-formulary on my plan?
A: You can request a formulary exception by documenting medical necessity and contraindications to covered alternatives.

Q: Can I request an expedited appeal?
A: Yes, if your doctor certifies that waiting would seriously jeopardize your health. Both BCBSM and Michigan DIFS offer expedited processes.

Q: Does step therapy apply if I've failed treatments outside Michigan?
A: Yes, BCBSM will consider prior therapy failures from other states if properly documented in medical records.

Q: What's the success rate for external appeals in Michigan?
A: While specific rates aren't published, Michigan DIFS has overturned BCBSM denials when clinical evidence strongly supports medical necessity.

Resources & Next Steps

For immediate help:

  • BCBSM Member Services: Number on your ID card
  • Michigan DIFS Consumer Hotline: 877-999-6442
  • Genentech Access Solutions: 1-844-4ACCESS

Official forms and policies:

Financial assistance:

  • Genentech Patient Foundation
  • CancerCare Co-Payment Assistance
  • Michigan Medicaid (if eligible)

About Coverage Appeals Support

When facing complex prior authorization denials, many patients and providers turn to specialized services that help navigate insurance requirements. Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to each plan's own rules.

For Alecensa appeals, having the right clinical evidence—FDA labeling, peer-reviewed studies, and specialty guidelines—properly integrated with required clinical facts like diagnosis codes, prior treatment failures, and dosing rationale can significantly improve approval odds. While this guide provides the framework for Michigan BCBSM appeals, complex cases often benefit from specialized support that understands payer-specific workflows and procedural requirements.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with Blue Cross Blue Shield of Michigan and consult your healthcare provider for medical decisions. For official appeals guidance, contact Michigan DIFS at 877-999-6442 or visit michigan.gov/difs.

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