By Counterforce Health Team in Alecensa (alectinib) —

Get Alecensa (Alectinib) Covered by Blue Cross Blue Shield in Washington: Complete Guide with Forms, Appeals, and Support

Answer Box: Getting Alecensa (Alectinib) Covered by Blue Cross Blue Shield in Washington

Alecensa requires prior authorization from Blue Cross Blue Shield plans in Washington for ALK-positive NSCLC. Start here: Verify your specific BCBS plan (Premera or Regence), download the current PA form from your plan's provider portal, and ensure ALK mutation testing results are attached. Submit through your plan's electronic system or fax with complete clinical documentation including diagnosis, prior treatments, and monitoring plan. If denied, Washington offers strong appeal rights including external review through Independent Review Organizations (IROs).

First step today: Call your BCBS member services number (on your card) to confirm PA requirements and get the correct submission portal or form.

Table of Contents

Start Here: Verify Your Plan and Requirements

Before submitting any paperwork, confirm which Blue Cross Blue Shield plan you have in Washington. The two main carriers are:

  • Premera Blue Cross (serving most commercial and individual plans)
  • Regence BlueShield (serving federal employees and some employer groups)

Each has different forms, portals, and submission requirements for Alecensa prior authorization.

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for ALK+ NSCLC Plan's PA drug list
Age Requirement ≥18 years PA criteria documents
Diagnosis Documentation ALK-positive mutation test results Submit with PA request
Monitoring Agreement Liver function tests (AST, ALT, bilirubin) Prescriber attestation required
Dosage Limit Up to 1,200 mg/day for 12 months Plan-specific policies
Specialty Pharmacy Must use in-network (Accredo or AllianceRx) Premera specialty pharmacy page

Required Forms and Documentation

For Premera Blue Cross Members

Download the current prior authorization form from Premera's provider forms page. The form varies by plan type (commercial, HMO, Medicare Advantage).

Required Clinical Documentation:

  • ALK mutation testing results (positive confirmation)
  • Complete diagnosis with ICD-10 codes
  • Prior treatment history and outcomes
  • Current staging and disease status
  • Prescriber agreement to monitor liver function
  • Dosing rationale and treatment plan

For Regence BlueShield Members

Access forms through Regence's provider pre-authorization page. Federal employee plans may have additional requirements.

Tip: Always download the most current form version. PA requirements can change quarterly, and using outdated forms causes delays.

Submission Portals and Methods

Electronic Submission Options

Premera Blue Cross:

  • Primary: Plan-specific provider portal
  • Alternative: CoverMyMeds for select plans
  • Availity Essentials (verify current availability)

Regence BlueShield:

  • Provider portal (main method)
  • Electronic Provider Access tool for out-of-area providers
  • Phone: 1-800-676-BLUE for BlueCard members

Required Portal Accounts

Most electronic submissions require provider enrollment and credentialing with the specific BCBS plan. Contact your plan's provider services to establish portal access if needed.

Fax and Mail Instructions

Premera Blue Cross

Commercial Plan Appeals:

  • Fax: 425-918-5592
  • Mail: Premera Blue Cross, ATN: Appeals Department, P.O. Box 91102, Seattle, WA 98111-9202

Regence BlueShield

Contact provider services at 1-877-668-4651 for current fax numbers and mailing addresses.

Note: Do not submit appeals through Availity or general customer service portals. Use the dedicated appeals fax or mail addresses only.

Cover Sheet Best Practices

  • Include member ID, provider NPI, and urgent designation if applicable
  • List total pages being faxed
  • Include direct callback number for questions
  • Mark "CONFIDENTIAL MEDICAL INFORMATION"

Specialty Pharmacy Network

Alecensa must be dispensed through an in-network specialty pharmacy for coverage. Washington BCBS plans primarily use:

In-Network Specialty Pharmacies

  • Accredo (Express Scripts specialty pharmacy)
  • AllianceRx Walgreens Prime (select plans only)

Enrollment Process

  1. Your prescriber sends the prescription to the designated specialty pharmacy
  2. The pharmacy initiates prior authorization if not already completed
  3. Patient enrollment includes insurance verification and copay assistance setup
  4. Home delivery is arranged (typically 3-5 business days)

Contact your plan's member services to confirm which specialty pharmacy is in-network for your specific plan.

Support Lines and Case Management

Member Services Contact Numbers

Service Premera Blue Cross Regence BlueShield
General Customer Service 1-800-562-1011 (FEHB)
1-800-550-1722 (PSHB)		 1-800-552-0733 (FEHB)
1-800-237-6734 (PSHB)
Prior Authorization 1-800-344-2227 1-800-344-2227
Provider Services Call customer service 1-877-668-4651
24/7 Pharmacy Support 1-800-722-1471 1-888-675-6570

Case Management Programs

Both Premera and Regence offer oncology case management for complex cancer treatments. Ask your customer service representative about enrollment if you're starting Alecensa therapy.

What to Ask When Calling:

  • Current PA status and timeline
  • Required documentation checklist
  • Expedited review options for urgent cases
  • Specialty pharmacy enrollment assistance
  • Appeal rights and deadlines

Washington State Appeals and External Review

Washington offers robust appeal rights for insurance denials, including external review through Independent Review Organizations (IROs).

Appeals Timeline

Level Timeframe Process
Internal Appeal Level I 30 days standard, 72 hours expedited Submit to plan's appeals department
Internal Appeal Level II 30 days standard If Level I denied
External Review (IRO) Within 180 days of final denial Request through Washington OIC
IRO Decision 30 days standard, 72 hours expedited Binding on insurer

How to Request External Review

  1. Complete internal appeals with your BCBS plan first
  2. Contact Washington Office of Insurance Commissioner at 1-800-562-6900
  3. Submit request within 180 days of final internal denial
  4. Provide all documentation including denial letters, medical records, and clinical rationale

The Washington OIC website provides detailed guidance and forms for external review requests.

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Missing ALK test results Submit molecular pathology report Laboratory report showing ALK rearrangement
Insufficient prior therapy documentation Provide treatment history Previous oncology notes, imaging, response data
Step therapy requirements Request medical exception Clinical rationale for Alecensa as first-line
Dosing concerns Justify weight-based dosing Patient weight, BSA calculation, dosing rationale
Monitoring plan unclear Submit detailed monitoring schedule LFT monitoring plan, frequency, safety parameters

Medical Necessity Letter Checklist

For Clinicians preparing appeals:

  • Patient's specific ALK mutation type and testing method
  • Disease stage and extent (metastatic vs. adjuvant setting)
  • Prior treatment failures or contraindications
  • Expected clinical benefit and treatment goals
  • Monitoring plan for hepatotoxicity and other adverse effects
  • Citations from FDA labeling and NCCN guidelines

Cost Assistance Programs

Manufacturer Support

Genentech Patient Foundation offers financial assistance for eligible patients:

  • Copay assistance for insured patients
  • Free drug program for uninsured/underinsured
  • Application available at Genentech Access Solutions

State and Federal Programs

  • Washington Apple Health (Medicaid) for eligible low-income patients
  • Medicare Extra Help for prescription drug costs
  • 340B pricing through qualified health centers
From our advocates: "We've seen patients reduce their Alecensa copay from $3,000+ per month to $5-10 through manufacturer assistance programs. The key is applying before the first fill and working with your specialty pharmacy to coordinate benefits. Don't assume you won't qualify—income limits are often higher than expected, and temporary assistance is available during appeals."

When to Escalate

Contact the Washington Office of Insurance Commissioner if you experience:

  • Repeated denials without clear clinical rationale
  • Delays beyond stated timeframes
  • Difficulty accessing required forms or information
  • Concerns about plan compliance with state regulations

OIC Consumer Advocacy: 1-800-562-6900 Online complaint form: Available at insurance.wa.gov

Update Schedule and Resources

How Often to Check for Changes

  • Formulary updates: January 1st annually, with mid-year changes possible
  • PA criteria: Quarterly reviews by most plans
  • Forms and processes: Check before each new submission

Key Resources to Bookmark

How Counterforce Health Can Help

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, identifies the specific denial basis, and drafts point-by-point rebuttals aligned to your plan's own rules. For complex cases like Alecensa appeals, we pull the right clinical evidence—FDA labeling, peer-reviewed studies, and specialty guidelines—and weave them into appeals that meet Washington's procedural requirements while tracking deadlines and required documentation.

Frequently Asked Questions

How long does BCBS prior authorization take in Washington? Standard PA requests typically take 5-10 business days. Expedited requests for urgent cases are processed within 72 hours.

What if Alecensa is non-formulary on my plan? You can request a formulary exception with clinical justification. This requires demonstrating medical necessity and why formulary alternatives are inappropriate.

Can I request an expedited appeal in Washington? Yes, if your health could be in serious jeopardy due to delays. Both internal and external appeals offer expedited timelines (72 hours vs. 30 days).

Does step therapy apply if I've failed treatments outside Washington? Treatment history from other states should be accepted with proper documentation. Include complete records from previous providers.

What happens if my external review is approved? The IRO decision is binding on your insurer. They must provide coverage and cannot appeal the decision.

Sources and Further Reading

For additional support with complex appeals, Counterforce Health offers specialized assistance in developing evidence-based appeal strategies for specialty cancer medications.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific guidance. Coverage policies and requirements may change. Verify current information with official sources before making healthcare decisions.

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