By Counterforce Health Team in Breyanzi (lisocabtagene maraleucel) —

Do You Qualify for Breyanzi (lisocabtagene maraleucel) Coverage by Aetna (CVS Health) in Texas? Decision Tree & Next Steps

Answer Box: Your Path to Breyanzi Coverage in Texas

Breyanzi (lisocabtagene maraleucel) requires prior authorization from Aetna CVS Health in Texas. You're likely eligible if you have relapsed/refractory large B-cell lymphoma after 2+ prior therapies, ECOG performance status 0-2, and treatment at a certified facility. First step today: Have your oncologist gather your treatment history, recent imaging, and pathology reports. Submit your prior authorization through Aetna's Availity portal or fax to 1-877-269-9916. If denied, Texas law gives you 4 years to appeal and guarantees external review within 72 hours for urgent cases.

Table of Contents

How to Use This Decision Tree

This guide helps you determine if you qualify for Breyanzi coverage through Aetna CVS Health in Texas and shows you exactly what to do next. Start with the eligibility triage below—it'll place you in one of four categories with specific action steps.

Breyanzi is an FDA-approved CAR-T cell therapy for adults with relapsed or refractory large B-cell lymphoma (LBCL) who've failed previous treatments. The therapy costs approximately $447,000-$487,000, making insurance approval critical.

Note: This guide covers commercial Aetna plans. If you have Medicaid or Medicare, some requirements may differ—contact your plan directly.

Eligibility Triage: Do You Qualify?

Answer these questions to find your path forward:

1. Diagnosis Confirmed?

  • ✓ Yes: You have biopsy-confirmed DLBCL (not otherwise specified), high-grade B-cell lymphoma, primary mediastinal large B-cell lymphoma, or grade 3B follicular lymphoma
  • ✗ No: You have primary CNS lymphoma, CLL, or another lymphoma subtype

2. Prior Therapy Requirements Met?

  • ✓ Yes: You've failed 2+ lines of systemic therapy with documented progression or intolerance
  • ✗ No: This is first-line treatment or you've only tried one prior therapy

3. Performance Status Adequate?

  • ✓ Yes: Your ECOG performance status is 0, 1, or 2
  • ✗ No: Your ECOG is 3 or higher

4. Medical Fitness?

  • ✓ Yes: Recent labs show adequate organ function, no active infections, no prior CAR-T therapy
  • ✗ No: You have contraindications listed in the FDA label

Your Results:

  • All ✓ = "Likely Eligible" → Go to approval checklist
  • Mostly ✓ = "Possibly Eligible" → Additional tests needed
  • Mostly ✗ = "Not Yet Eligible" → Consider alternatives
  • Any category can appeal if denied → Use Texas appeal process

If "Likely Eligible": Your Approval Checklist

You meet the basic criteria. Here's your document checklist and submission path:

Required Documentation

Clinical Records (within 30 days):

  • Pathology report confirming eligible LBCL subtype
  • Recent imaging (PET/CT) showing active disease
  • ECOG performance status documentation
  • Complete blood count, comprehensive metabolic panel
  • Hepatitis B/C and HIV screening results

Treatment History:

  • Names, dates, and outcomes of all prior therapies
  • Documentation of progression or intolerance
  • Reason for transplant ineligibility (if applicable)

Facility Requirements:

  • Confirmation your treatment center is certified for CAR-T therapy
  • Evidence of tocilizumab availability and ICU access

Submission Process

  1. Complete Aetna's prior authorization form (available through Availity provider portal)
  2. Submit via:
    • Availity portal (preferred for providers)
    • Fax: 1-877-269-9916
  3. Timeline: Standard decision within 45 business days; expedited within 72 hours if urgent
  4. Follow up: Contact CVS Specialty Pharmacy at 1-888-632-3862 once approved

If "Possibly Eligible": Tests and Timeline

You may qualify but need additional documentation. Work with your oncologist to obtain:

Additional Testing Needed

  • Updated performance status assessment if last evaluation was >30 days ago
  • Repeat imaging to confirm active, measurable disease
  • Organ function tests if previous results are outdated
  • Infectious disease clearance

Timeline to Reapply

  • Gather missing documentation: 1-2 weeks
  • Resubmit prior authorization: Once complete
  • Consider expedited review if your condition is deteriorating
Tip: Don't wait for perfect documentation. Submit what you have and supplement with additional records as they become available.

If "Not Yet Eligible": Alternatives and Exceptions

If you don't meet standard criteria, you still have options:

Alternative Treatments to Discuss

  • Other CD19 CAR-T therapies (Yescarta, Kymriah) if they have different eligibility criteria
  • Clinical trials for investigational CAR-T products
  • Bridging therapy to improve performance status or organ function

Exception Request Strategy

File a formulary exception with Aetna by demonstrating:

  • Medical necessity despite not meeting all criteria
  • Lack of suitable alternatives
  • Potential for meaningful clinical benefit
  • Supporting literature for off-label use (if applicable)

If Denied: Texas Appeal Path

Texas law provides strong patient protections with extended deadlines and rapid review for urgent cases.

Internal Appeal (First Level)

  • Deadline: 4 years from denial date (Texas law overrides Aetna's 180-day standard)
  • Decision time: 45 business days (standard) or 72 hours (expedited)
  • How to file: Submit through Availity portal or mail to Aetna appeals department
  • Required: Denial letter, medical records, prescriber letter of medical necessity

External Review (Independent Review Organization)

  • When available: After final internal denial or concurrently for life-threatening conditions
  • Deadline: 4 months from final internal denial
  • Decision time: 72 hours (expedited) or 20 days (standard)
  • Filing fee: Up to $650 (waivable for financial hardship)
  • Oversight: Texas Department of Insurance
From our advocates: We've seen Breyanzi denials overturned in Texas when families provided comprehensive documentation of failed prior therapies and emphasized the urgent nature of progressive lymphoma. The key is requesting expedited review and clearly articulating why delay threatens the patient's life or health.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all indications Aetna Availity portal Aetna Precert List
Eligible Diagnosis DLBCL, PMBCL, HGBCL, FL grade 3B FDA label FDA Prescribing Information
Prior Therapies ≥2 lines of systemic therapy Treatment records Aetna Clinical Policy
Performance Status ECOG 0-2 Recent clinic note Aetna Clinical Policy
Age Requirement 18+ years Medical record Aetna Clinical Policy
Facility Certification CAR-T certified center No REMS required in Texas Texas Medicaid Update

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
"Not medically necessary" Submit detailed letter explaining disease progression, failed alternatives, and guideline support
"Experimental/investigational" Provide FDA approval letter and on-label use documentation
"Inadequate prior therapy documentation" Obtain complete treatment records with dates, drug names, and progression notes
"Performance status too poor" Request updated ECOG assessment if condition has improved
"Facility not certified" Confirm treatment center meets Texas requirements (REMS no longer required)

Costs and Financial Support

List Price: ~$447,000-$487,000 for the drug alone; total treatment costs often exceed $600,000 with hospitalization and monitoring.

Financial Assistance Options:

  • Bristol Myers Squibb Cell Therapy 360: Patient support program offering financial assistance and case management
  • Leukemia & Lymphoma Society: Copay assistance and travel grants
  • CancerCare: Financial assistance for treatment-related expenses
  • State programs: Texas has limited specialty drug assistance; check with your county health department

FAQ: Texas-Specific Questions

How long does Aetna CVS Health prior authorization take in Texas? Standard decisions within 45 business days; expedited decisions within 72 hours for urgent cases.

What if Breyanzi is non-formulary on my plan? Request a formulary exception with medical necessity documentation. Texas law requires coverage of medically necessary treatments even if non-formulary.

Can I request an expedited appeal in Texas? Yes, if delay would jeopardize your life or health. Both internal appeals and external reviews can be expedited with 72-hour decision timelines.

Does step therapy apply to CAR-T therapies? Generally no. Breyanzi is reserved for patients who've already failed multiple therapies, so traditional step therapy doesn't apply.

What happens if I need emergency care after Breyanzi? Emergency care is covered regardless of prior authorization status. Seek immediate medical attention for severe side effects.

How do I find a certified CAR-T center in Texas? As of October 2025, Texas no longer requires REMS certification. Contact major cancer centers to confirm their CAR-T capabilities and Aetna network status.

Getting insurance approval for specialty therapies like Breyanzi can feel overwhelming, but you don't have to navigate it alone. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, identifies the specific basis for rejection, and drafts point-by-point rebuttals using the right medical evidence and clinical facts that payers expect. Whether you're facing a prior authorization denial or need help preparing a comprehensive appeal, we help patients and clinicians get prescription drugs approved by aligning appeals to each plan's own rules and requirements.

Sources & Further Reading

This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for personalized guidance. For additional help with Texas insurance appeals, contact the Texas Department of Insurance at 1-800-252-3439 or the Office of Public Insurance Counsel at 1-877-611-6742.

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