How long does prior authorization take for Breyanzi with BCBS Washington?

Blue Cross Blue Shield typically processes prior authorization requests for specialty drugs like Breyanzi within 15 business days, though urgent cases may be expedited within 72 hours.

What documentation is required for Breyanzi prior authorization?

Required documentation includes complete medical history, pathology reports confirming diagnosis, documentation of prior treatments and failures, current disease status, treatment center certification, and detailed treatment plan from your oncologist.

Can I appeal a Breyanzi coverage denial from Blue Cross Blue Shield?

Yes, you have the right to appeal coverage denials. The appeal process includes internal review by BCBS, external independent review, and potentially state insurance commissioner involvement if needed.

By Counterforce Health Team in Breyanzi (lisocabtagene maraleucel) — 26 Nov 2025

Do You Qualify for Breyanzi Coverage by Blue Cross Blue Shield in Washington? Decision Tree & Next Steps

Name: Do You Qualify for Breyanzi Coverage by Blue Cross Blue Shield in Washington? Decision Tree & Next Steps
Creator: Counterforce Health
Published: 2025-11-26

Answer Box: Your Fastest Path to Breyanzi Coverage

To get Breyanzi (lisocabtagene maraleucel) covered by Blue Cross Blue Shield in Washington:

Confirm eligibility: You need relapsed/refractory large B-cell lymphoma after ≥2 lines OR CLL/SLL after ≥2 lines including BTK and BCL-2 inhibitors
Submit prior authorization: Your oncologist must complete BCBS specialty drug exception form with detailed medical necessity documentation
Use approved center: Treatment must occur at a FACT-accredited facility like Fred Hutchinson Cancer Center

Timeline: 3-5 business days for PA decision. If denied, you have 60 days to file external review with Washington's Insurance Commissioner. Cost: ~$447,000-487,000 WAC price.

Start today: Contact your oncologist to begin PA paperwork and verify your treatment center is BCBS-approved.

How to Use This Decision Tree
Eligibility Triage: Do You Qualify?
If "Likely Eligible": Document Checklist
If "Possibly Eligible": Tests to Request
If "Not Yet": Alternatives to Discuss
If Denied: Appeal Path Chooser
Coverage Requirements at a Glance
Common Denial Reasons & How to Fix Them
Washington Appeals Process
FAQ

How to Use This Decision Tree

This guide helps you navigate Breyanzi coverage with Blue Cross Blue Shield (BCBS) in Washington state. Work through the eligibility questions below, then follow the specific pathway that matches your situation.

Important: This is not medical advice. Always work with your oncologist and verify current policies with your specific BCBS plan.

What you'll need:

Your BCBS member ID and policy details
Complete medical records and treatment history
Contact information for your oncology team
List of all prior therapies tried and their outcomes

Eligibility Triage: Do You Qualify?

Diagnosis Confirmed?

For Large B-Cell Lymphoma (LBCL):

✅ Yes, if you have: Diffuse large B-cell lymphoma (DLBCL), high-grade B-cell lymphoma, primary mediastinal B-cell lymphoma, or follicular lymphoma grade 3B
❌ No, if you have: Primary CNS lymphoma, other lymphoma subtypes not listed above

For CLL/SLL:

✅ Yes, if you have: Chronic lymphocytic leukemia or small lymphocytic lymphoma confirmed by pathology

Prior Therapy Requirements Met?

LBCL Second-Line Eligibility:

✅ Refractory to first-line chemoimmunotherapy, OR
✅ Relapsed within 12 months of first-line treatment, OR
✅ Relapsed/refractory after first-line AND ineligible for stem cell transplant

CLL/SLL Requirements:

✅ Failed ≥2 prior lines of therapy
✅ Must include BOTH a BTK inhibitor (like ibrutinib) AND a BCL-2 inhibitor (like venetoclax)

Age and Performance Status?

✅ Age 18 or older
✅ Adequate performance status for CAR-T therapy
✅ No active uncontrolled infections
✅ Adequate organ function (heart, liver, kidney)

If "Likely Eligible": Document Checklist

You meet the basic criteria. Here's what your oncologist needs to submit for prior authorization:

Required Documentation

Medical Records Package:

Pathology report confirming eligible lymphoma subtype
Complete treatment history with dates, drugs, and outcomes
Documentation of refractoriness or relapse timing
Recent imaging showing disease status
Lab results (CBC, comprehensive metabolic panel, LDH)
Performance status assessment (ECOG or Karnofsky)

Prior Authorization Form:

BCBS specialty drug exception request form
Medical necessity letter citing FDA approval criteria
Step therapy override justification (if applicable)

Submission Process

Your oncologist completes the PA form with detailed clinical rationale
Submit via BCBS provider portal or fax (verify current submission method with your plan)
Timeline: 3-5 business days for standard review
Expedited option: Available for urgent cases with clinical justification

Tip: Request expedited review if your disease is rapidly progressing or you have limited treatment options.

If "Possibly Eligible": Tests to Request

You may qualify but need additional documentation. Ask your oncologist about:

Additional Testing Needed

For LBCL patients:

Confirm transplant ineligibility with formal evaluation
Document specific reasons why standard therapies failed or are inappropriate
Obtain updated imaging to confirm relapsed/refractory status

For CLL/SLL patients:

Verify you've received both required drug classes (BTK + BCL-2 inhibitors)
Document treatment failures with specific dates and response assessments
Confirm no contraindications to CAR-T therapy

Timeline to Re-apply

Complete additional testing within 2-4 weeks
Resubmit PA with comprehensive documentation
Most BCBS plans allow multiple PA attempts with new information

If "Not Yet": Alternatives to Discuss

You don't currently meet standard criteria. Consider these options:

Alternative Treatments

For LBCL: Other CAR-T products (Yescarta, Kymriah) may have different criteria
For CLL/SLL: Ensure you've tried all required prior therapies first
Clinical trials: May provide access before meeting commercial criteria

Exception Request Strategy

Document why standard treatments are inappropriate
Provide evidence of rapid disease progression
Include expert opinion letters supporting early CAR-T use
Consider second opinion at major cancer center

Note: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing your specific denial reason and crafting point-by-point rebuttals using the right medical evidence and payer-specific workflows.

If Denied: Appeal Path Chooser

Level 1: Internal Appeal (First Step)

Timeline: Must file within 180 days of denial Process: Submit additional medical evidence and request reconsideration Success rate: Varies by plan; many process errors get resolved here

Level 2: Peer-to-Peer Review

Who: Your oncologist speaks directly with BCBS medical director When: If initial internal appeal denied Preparation: Have clinical guidelines and evidence ready

Level 3: External Review (Washington State)

Timeline: 60 days from final internal denial to request Process: Independent review organization (IRO) makes binding decision Contact: Washington Insurance Commissioner at 1-800-562-6900

Coverage Requirements at a Glance

Requirement	What It Means	Where to Find It
Prior Authorization	Required before treatment	BCBS member portal or provider services
FACT Accreditation	Treatment center must be certified	FACT website directory
FDA Indication	Must match approved uses exactly	FDA Breyanzi label
Step Therapy	May need to try other treatments first	Your specific BCBS plan documents
Single Dose	One treatment course only	BCBS medical policy

Common Denial Reasons & How to Fix Them

Denial Reason	How to Overturn
"Not meeting line of therapy"	Submit detailed treatment history with dates and outcomes
"Missing BTK/BCL-2 exposure" (CLL)	Document specific drugs tried and reasons for discontinuation
"Center not approved"	Transfer care to FACT-accredited facility in BCBS network
"Experimental/investigational"	Cite FDA approval and include label in appeal
"Medical necessity not established"	Provide comprehensive medical necessity letter with guidelines

Washington Appeals Process

Internal Appeals

First level: Submit within 180 days
Review time: 30 days (15 for urgent)
Submit to: Your BCBS plan's appeals department

External Review

Eligibility: After exhausting internal appeals
Timeline: 60 days to request, 20 days for decision
Cost: Free to you
Decision: Binding on BCBS

To initiate external review:

Contact Washington Insurance Commissioner at 1-800-562-6900
Submit request with all denial letters and medical records
IRO will assign independent medical experts to review
Decision typically comes within 2-3 weeks

From our advocates: We've seen many Washington patients successfully overturn CAR-T denials through external review, especially when the denial was based on overly restrictive interpretation of medical necessity criteria. The key is comprehensive documentation and persistence through the process.

FAQ

How long does BCBS prior authorization take in Washington? Standard PA decisions come within 3-5 business days. Expedited reviews for urgent cases are processed within 72 hours.

What if Breyanzi is non-formulary on my plan? You can request a formulary exception with medical necessity documentation. Your oncologist must demonstrate why Breyanzi is more appropriate than formulary alternatives.

Can I request an expedited appeal? Yes, if your condition could seriously deteriorate during standard review timelines. Your doctor must provide clinical justification for urgency.

Does step therapy apply if I failed treatments outside Washington? Treatment history from any state counts toward step therapy requirements. Provide complete records regardless of where treatment occurred.

What centers in Washington can administer Breyanzi? Major options include Fred Hutchinson Cancer Center and Seattle Cancer Care Alliance. Verify current BCBS network status and FACT accreditation before scheduling.

How much does Breyanzi cost without insurance? The wholesale acquisition cost (WAC) is approximately $447,000-487,000 per dose, with total treatment costs potentially higher when including administration and monitoring.

What if my employer plan is self-funded? Self-funded ERISA plans may have different appeal rights. Contact the U.S. Department of Labor if Washington state external review isn't available.

Can I get help with the appeal process? Yes. Contact the Washington Insurance Commissioner's consumer advocacy line at 1-800-562-6900 for free assistance. Counterforce Health also provides specialized support for complex coverage appeals.

Sources & Further Reading

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Treatment decisions should always be made in consultation with qualified healthcare providers. Insurance coverage policies change frequently; verify current requirements with your specific plan. For personalized assistance with coverage appeals, consult with patient advocacy organizations or legal counsel specializing in healthcare coverage.

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