By Counterforce Health Team in Breyanzi (lisocabtagene maraleucel) —

Do You Qualify for Breyanzi Coverage by Humana in Illinois? Decision Tree & Next Steps

Answer Box: Getting Breyanzi Covered by Humana in Illinois

Yes, you can get Breyanzi (lisocabtagene maraleucel) covered by Humana in Illinois if you meet FDA-approved criteria for relapsed/refractory large B-cell lymphoma or CLL/SLL. Humana requires prior authorization with complete clinical documentation. First step: Verify your diagnosis matches FDA labeling, gather prior therapy records, and have your CAR-T center submit electronic PA via Humana's provider portal. If denied, Illinois law gives you 30 days to file an expedited external review through the Illinois Department of Insurance. Most approvals happen within 1-2 business days when documentation is complete.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible": Your Path to Approval
  4. If "Possibly Eligible": Tests and Timeline
  5. If "Not Yet Eligible": Alternatives and Preparation
  6. If Denied: Illinois Appeal Path Chooser
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & How to Fix Them
  9. FAQ: Breyanzi Coverage in Illinois

How to Use This Decision Tree

This guide helps Illinois patients and their clinicians navigate Humana's prior authorization process for Breyanzi (lisocabtagene maraleucel). We'll walk through eligibility requirements, documentation needs, and appeal options specific to Illinois law.

Before you start: Gather your insurance card, recent pathology reports, treatment history, and current lab results. Most successful approvals include complete documentation from day one.

Eligibility Triage: Do You Qualify?

Step 1: Confirm Your Diagnosis

Large B-Cell Lymphoma (LBCL) - You likely qualify if you have:

  • Diffuse large B-cell lymphoma (DLBCL), not otherwise specified
  • High-grade B-cell lymphoma (HGBCL)
  • Primary mediastinal large B-cell lymphoma (PMBCL)
  • Follicular lymphoma grade 3B

Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma (CLL/SLL) - You likely qualify with confirmed CLL or SLL diagnosis.

Step 2: Check Prior Therapy Requirements

For LBCL:

  • ✅ Likely eligible: Failed ≥2 prior lines of therapy, OR failed first-line therapy and either relapsed within 12 months OR are not eligible for stem cell transplant
  • ⚠️ Possibly eligible: Currently on first-line therapy but showing resistance
  • ❌ Not yet: Haven't tried standard first-line treatment

For CLL/SLL:

  • ✅ Likely eligible: Failed ≥2 prior therapies including BOTH a BTK inhibitor (ibrutinib, acalabrutinib, zanubrutinib) AND a BCL-2 inhibitor (venetoclax)
  • ⚠️ Possibly eligible: Failed one of these drug classes but not both
  • ❌ Not yet: Haven't tried BTK or BCL-2 inhibitors

Step 3: Assess Clinical Status

Required for all patients:

  • Age 18 or older
  • ECOG performance status 0-2 (able to care for yourself)
  • Adequate organ function (heart, kidney, liver)
  • No active, uncontrolled infections
  • Available for monitoring at a certified CAR-T center

If "Likely Eligible": Your Path to Approval

Document Checklist for Humana PA

Patient Information:

  • Full name, DOB, Humana member ID
  • Plan type (verify if Medicare Advantage or commercial)
  • Treating facility with BREYANZI REMS certification

Clinical Documentation:

  • Primary diagnosis with ICD-10 code
  • Pathology report confirming B-cell lymphoma subtype or CLL/SLL
  • Staging information and current disease burden
  • Performance status (ECOG 0-2)

Treatment History:

  • Complete list of prior therapies with dates and responses
  • Documentation of treatment failure or intolerance
  • For CLL/SLL: specific proof of BTK and BCL-2 inhibitor exposure

Safety Requirements:

  • Recent labs: CBC, comprehensive metabolic panel, liver function
  • Cardiac function assessment (LVEF ≥40%)
  • Infection screening results
  • Confirmation of 24/7 monitoring capability at treatment center

Submission Process

  1. Electronic Submission Preferred: Use Humana's provider portal for fastest processing
  2. Request Expedited Review: Given the life-threatening nature of relapsed lymphoma/leukemia
  3. Expected Timeline: 95% of complete electronic PAs decided within 1 business day by 2026
  4. Follow Up: Track status through provider portal
Tip: Humana's PA denial rate is only 3.5% when complete documentation is submitted. Most denials result from missing clinical information rather than coverage exclusions.

If "Possibly Eligible": Tests and Timeline

Additional Testing Needed

If diagnosis is uncertain:

  • Flow cytometry to confirm B-cell markers (CD19, CD20)
  • Repeat biopsy if original pathology is unclear
  • Staging scans (PET/CT) to assess disease extent

If prior therapy documentation is incomplete:

  • Obtain complete treatment records from all providers
  • Document specific drug names, doses, duration, and response
  • For CLL/SLL: confirm both BTK and BCL-2 inhibitor exposure

Timeline to Reapply

  • Diagnostic clarification: 2-4 weeks for repeat testing
  • Treatment history: 1-2 weeks to gather records
  • Resubmission: Immediately after obtaining missing documentation

If "Not Yet Eligible": Alternatives and Preparation

Standard Treatment Options to Discuss

For LBCL:

  • Complete first-line chemoimmunotherapy if not yet tried
  • Consider clinical trials
  • Evaluate for autologous stem cell transplant eligibility

For CLL/SLL:

  • Try BTK inhibitor if not yet exposed
  • Consider venetoclax-based therapy if BCL-2 inhibitor naive
  • Discuss clinical trial options

Preparing for Future Breyanzi Request

  • Document all treatment responses and toxicities
  • Maintain relationship with CAR-T certified center
  • Consider second opinion at major Illinois cancer center
  • Track disease progression markers

If Denied: Illinois Appeal Path Chooser

Level 1: Internal Appeal with Humana

Timeline: 65 days from denial notice Process: Submit additional clinical documentation addressing denial reason Expected Decision: 30 days for standard, 72 hours for expedited

Level 2: Illinois External Review

Illinois provides one of the fastest external review processes in the country:

Who Qualifies: Any medical necessity or experimental/investigational denial Timeline: 30 days from internal appeal denial (strict Illinois deadline) Process:

  • File Request for External Review with Illinois Department of Insurance
  • Include Provider Certification for expedited review
  • Independent physician reviewer makes binding decision

Expected Timeline:

  • Standard: 45 days from filing
  • Expedited: 72 hours (typical for CAR-T given urgency)

When to Get Help

Illinois Department of Insurance: (877) 527-9431 Illinois Attorney General Health Care Helpline: (877) 305-5145

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required before treatment Humana PA Search Tool
REMS Certified Center Must treat at certified facility FDA REMS database
FDA-Approved Indication Diagnosis must match label FDA Prescribing Information
Prior Therapy Documentation Complete treatment history required Medical records
Performance Status ECOG 0-2 typically required Clinical assessment
Organ Function Heart, kidney, liver tests Laboratory results

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
"Not medically necessary" Submit detailed medical necessity letter with NCCN guidelines, prior therapy failures, and prognosis without treatment
"Experimental/investigational" Provide FDA approval documentation and published clinical trial data showing efficacy
"Insufficient prior therapy" Document complete treatment history with dates, responses, and reasons for discontinuation
"Non-contracted facility" Request single case agreement or transfer to in-network CAR-T center
"Missing documentation" Provide complete pathology, staging, lab results, and performance status assessment

FAQ: Breyanzi Coverage in Illinois

How long does Humana prior authorization take in Illinois? Humana targets 1 business day for complete electronic submissions. Incomplete requests may take up to 30 days.

What if Breyanzi is not on Humana's formulary? CAR-T therapies like Breyanzi are typically covered under medical benefits (Part B/Medicare Advantage), not pharmacy formulary. Coverage is based on medical necessity rather than formulary status.

Can I request expedited review? Yes. Given the life-threatening nature of relapsed lymphoma/leukemia, most Breyanzi requests qualify for expedited processing (24-72 hours).

Does step therapy apply if I failed treatments outside Illinois? No. Treatment history from any licensed provider counts toward prior therapy requirements.

What's the cost if approved? List price is approximately $447,000-$487,000. Your out-of-pocket cost depends on your specific Humana plan's coinsurance and out-of-pocket maximum.

How do I find a certified treatment center in Illinois? Major academic medical centers like University of Chicago, Northwestern, and Rush typically offer CAR-T programs. Verify BREYANZI REMS certification with your chosen center.

From Our Advocates

"We've seen the strongest approvals when patients work closely with their CAR-T center's financial navigator to submit complete documentation upfront. Centers experienced with Humana's requirements can often anticipate and address potential issues before they become denials. The key is treating the PA as a comprehensive medical story, not just a form to fill out."

Getting Additional Support

If you're struggling with Humana's prior authorization process or need help appealing a denial, Counterforce Health specializes in turning insurance denials into successful appeals. Our platform analyzes denial letters, identifies the specific coverage gaps, and helps draft evidence-based appeals that address payer concerns directly.

For Illinois residents, we're particularly familiar with the state's external review process and can help you navigate the tight 30-day deadline for filing with the Illinois Department of Insurance.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual circumstances, plan details, and current policies. Always consult with your healthcare provider and insurance plan for personalized guidance. For official Illinois insurance assistance, contact the Illinois Department of Insurance at (877) 527-9431.

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