By Counterforce Health Team in Abecma (idecabtagene vicleucel) —

How to Get Abecma (idecabtagene vicleucel) Covered by Aetna (CVS Health) in Pennsylvania: Appeals Guide 2025

Answer Box: Getting Abecma Covered in Pennsylvania

Abecma (idecabtagene vicleucel) requires prior authorization from Aetna (CVS Health) in Pennsylvania. Submit through your oncologist at a certified CAR-T center with documentation of ≥4 prior therapy failures, adequate organ function, and NCCN guideline support. If denied, Pennsylvania's new external review program overturns ~50% of specialty drug denials. First step today: Contact your treatment center's financial counselor to initiate the prior authorization process through CVS Caremark at 1-866-785-5714.

Table of Contents

Understanding Abecma Coverage Requirements

Abecma is a groundbreaking CAR-T cell therapy for adults with relapsed or refractory multiple myeloma. Your T-cells are collected, genetically modified to target BCMA (a protein on myeloma cells), and then infused back into your body after lymphodepleting chemotherapy.

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all CAR-T therapies CVS Caremark portal or call 1-866-785-5714 CVS Caremark PA
Certified Treatment Center Must be administered at qualified facility Fox Chase Cancer Center, UPMC Hillman Abecma Treatment Centers
Line of Therapy ≥4 prior lines including IMiD, PI, anti-CD38 FDA prescribing information FDA Label
Performance Status ECOG 0-2, adequate organ function Medical records documentation Clinical assessment
Appeals Deadline 180 days from denial (Aetna standard) Member handbook Aetna policy

Aetna (CVS Health) typically covers Abecma when FDA criteria are met and it's administered at a certified center. However, the $498,410+ cost often triggers intensive utilization review.

Reading Your Denial Letter

When Aetna denies Abecma coverage, you'll receive a denial letter with specific reason codes. Common reasons include:

  • "Not medically necessary" - Usually means missing documentation of prior therapy failures
  • "Experimental/investigational" - Incorrect; Abecma is FDA-approved since March 2021
  • "Non-formulary" - Requires formulary exception with medical necessity documentation
  • "Site of care restriction" - Must be at certified CAR-T center
  • "Insufficient documentation" - Missing labs, performance status, or prior treatment records
Tip: The denial letter includes your appeal deadline (typically 180 days) and instructions for requesting an expedited review if your condition is rapidly progressing.

Fixable Causes of Denials

Many Abecma denials can be overturned by addressing documentation gaps:

Missing Clinical Documentation

  • Prior therapy records: Document all ≥4 prior lines with dates, doses, response, and reason for discontinuation
  • Performance status: Include recent ECOG assessment and functional status
  • Organ function: Recent labs showing adequate cardiac, renal, and hepatic function
  • Disease progression: Imaging or lab values showing active, progressive disease

Coding Issues

  • Ensure ICD-10 code C90.02 (relapsed/refractory multiple myeloma) is used
  • Verify treatment center is certified and contracted with Aetna

Policy Misinterpretation

  • Emphasize FDA approval and NCCN Category 1 recommendation
  • Highlight that patient meets exact FDA indication criteria

First-Level Appeal Strategy

Your oncologist should lead the appeal with a comprehensive medical necessity letter. Here's what to include:

Medical Necessity Letter Components

Patient History Section:

  • Diagnosis date and staging
  • Complete treatment history with specific agents, dates, best response, and progression
  • Current disease status with recent imaging/labs
  • Performance status and comorbidities

Clinical Rationale:

  • Why Abecma is medically necessary now
  • Why other treatments are inappropriate (exhausted, contraindicated, or ineffective)
  • Expected benefits and treatment goals
  • Urgency of treatment (disease progression)

Evidence Base:

  • FDA approval for this exact indication
  • NCCN Guidelines Category 1 recommendation
  • KarMMa trial data (73% overall response rate)
  • Peer-reviewed literature supporting efficacy

Required Supporting Documents

  • Complete medical records from all treating physicians
  • Pathology reports confirming multiple myeloma
  • Imaging showing disease progression
  • Lab values (CBC, chemistries, organ function)
  • Prior therapy summary with outcomes
  • NCCN Guidelines pages (verify current version)

At Counterforce Health, we help patients and clinicians navigate complex prior authorization and appeals processes for specialty therapies like Abecma. Our platform analyzes denial letters, identifies the specific approval pathway, and generates evidence-backed appeals that align with each payer's requirements—turning insurance obstacles into successful coverage outcomes.

Peer-to-Peer Review Process

If your initial appeal is denied, request a peer-to-peer review where your oncologist speaks directly with Aetna's medical director.

Scheduling the Call

Call CVS Caremark at 1-866-785-5714 and request a peer-to-peer review for the denied prior authorization. Have your:

  • PA reference number
  • Patient information
  • Oncologist's availability for the next 2-3 business days

Prep Checklist for Your Doctor

  • Review complete patient history and treatment timeline
  • Have NCCN Guidelines and FDA label readily available
  • Prepare 2-3 key points about why Abecma is the appropriate next step
  • Document the call outcome and any commitments made

Pennsylvania's External Review Program

Pennsylvania launched its Independent External Review (IER) program in 2024, giving patients a powerful tool to overturn insurance denials.

How It Works

  1. Complete Internal Appeals First: You must receive a "Final Adverse Benefit Determination" letter from Aetna
  2. File Within 4 Months: Submit your external review request within 4 months of the final denial
  3. Independent Medical Review: Pennsylvania assigns independent physicians to review your case
  4. Binding Decision: If the external reviewers approve coverage, Aetna must comply

Success Rates

Pennsylvania reports that approximately 50% of external reviews are decided in favor of patients, with insurers required to cover previously denied treatments.

How to File

Submit your request through the Pennsylvania Insurance Department website or call their consumer helpline for assistance.

Required Documents:

  • Final denial letter from Aetna
  • Copy of insurance card
  • Medical records supporting medical necessity
  • Physician letter explaining why Abecma is necessary

Appeal Templates and Scripts

Patient Phone Script for Aetna

"Hi, I'm calling about a denied prior authorization for Abecma, a CAR-T therapy for multiple myeloma. My PA reference number is [number]. I'd like to request an expedited appeal and peer-to-peer review. My doctor says this treatment is urgently needed because my cancer is progressing. Can you help me start this process today?"

Clinic Staff Script for Peer-to-Peer

"I'm calling to schedule a peer-to-peer review for [patient name], PA number [number]. Dr. [name] is the treating hematologist-oncologist and needs to discuss the medical necessity of Abecma with your medical director. The patient has relapsed/refractory multiple myeloma and has failed four prior lines of therapy per FDA criteria."

Tracking Your Appeal

Keep detailed records of all communications:

Appeal Tracking Log:

  • Date appeal submitted
  • Method of submission (portal, fax, mail)
  • Confirmation number received
  • Expected decision date
  • Follow-up calls made
  • Decision received and next steps

Set calendar reminders for follow-up calls every 7-10 business days until you receive a decision.

When Appeals Fail: Alternative Options

If Aetna upholds the denial even after external review, consider these alternatives:

Manufacturer Support Programs

Bristol Myers Squibb offers patient assistance through their Access Support program. Contact them at 1-855-ABECMA-1 (1-855-223-2621) to discuss:

  • Copay assistance (for commercially insured patients)
  • Free drug programs (for uninsured/underinsured patients)
  • Appeals support and documentation assistance

Alternative Therapies

Discuss these BCMA-targeted options with your oncologist:

  • Carvykti (ciltacabtagene autoleucel): Another CAR-T therapy that may have different coverage requirements
  • Teclistamab (Tecvayli): BCMA bispecific antibody given subcutaneously
  • Elranatamab (Elrexfio): Another BCMA bispecific with different dosing

Clinical Trials

If commercial therapy isn't accessible, ask your treatment center about ongoing CAR-T or other myeloma clinical trials.

From Our Advocates: "We've seen patients succeed by having their treatment center's financial counselor work directly with Counterforce Health to build comprehensive appeals. The key is documenting not just that prior therapies failed, but exactly how they failed—with specific dates, doses, and progression evidence. When we align this documentation with Aetna's specific policy language, approval rates increase significantly."

FAQ

How long does Aetna's prior authorization process take? Standard PA decisions are typically made within 30-45 business days. Expedited reviews (for urgent medical situations) are decided within 72 hours.

What if Abecma isn't on Aetna's formulary? You can request a formulary exception by submitting medical necessity documentation showing why preferred alternatives aren't appropriate for your specific case.

Can I get expedited review if my cancer is progressing? Yes. If your oncologist certifies that delay could seriously jeopardize your health, request expedited review when submitting your PA or appeal.

Does step therapy apply to CAR-T therapies? Aetna may require documentation that you've tried and failed standard multiple myeloma therapies, but this aligns with FDA approval criteria requiring ≥4 prior lines.

What happens if I start treatment before approval? CAR-T therapy requires extensive coordination and cannot be started without authorization. Work with your treatment center's financial team before beginning any steps of the process.

How much does Abecma cost if I pay out-of-pocket? The wholesale acquisition cost is approximately $498,410, with total episode costs potentially exceeding $750,000 including hospitalization and monitoring.

Can I appeal to Pennsylvania if I have a Medicare Advantage plan through Aetna? Medicare Advantage appeals follow federal Medicare rules, not Pennsylvania's external review program. However, you still have appeal rights through Medicare's process.

What if I live near the border—can I get treatment in another state? Yes, but verify that your Aetna plan covers out-of-network care at the treatment center. Some plans require in-network providers for coverage.

This information is for educational purposes only and should not replace professional medical or legal advice. Always consult with your healthcare team and insurance plan for the most current coverage requirements.

Need help navigating your specific situation? Counterforce Health specializes in turning insurance denials into successful appeals by analyzing your denial letter and building targeted, evidence-backed responses that speak directly to your payer's requirements.

Sources & Further Reading

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