By Counterforce Health Team in Alecensa (alectinib) —

How to Get Alecensa (alectinib) Covered by Blue Cross Blue Shield in Pennsylvania: Appeals Guide & Forms

Answer Box: Getting Alecensa (alectinib) Covered by Blue Cross Blue Shield in Pennsylvania

Fastest path to approval: Submit prior authorization with ALK-positive test results, surgical history (for adjuvant use), and medical necessity letter citing FDA approval and NCCN guidelines. If denied, file internal appeal within plan deadlines, then request Pennsylvania's external review within 4 months. First step today: Call the number on your insurance card to confirm formulary status and PA requirements, or have your doctor submit through the Carelon provider portal.

Table of Contents

  1. Understanding Blue Cross Blue Shield Coverage in Pennsylvania
  2. Prior Authorization Requirements for Alecensa
  3. Common Denial Reasons & How to Fix Them
  4. Step-by-Step Appeals Process
  5. Medical Necessity Documentation
  6. Pennsylvania External Review Program
  7. Templates & Scripts
  8. Cost Assistance Options
  9. FAQ

Understanding Blue Cross Blue Shield Coverage in Pennsylvania

Pennsylvania's Blue Cross Blue Shield landscape includes Highmark Blue Shield (western PA, ~31% market share) and Independence Blue Cross (Philadelphia region). Both plans typically classify Alecensa as a specialty-tier medication requiring prior authorization for ALK-positive non-small cell lung cancer (NSCLC).

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required before dispensing IBX formulary or Highmark member portal
ALK Testing Must confirm ALK-positive mutation Pathology report with IHC/FISH results
Specialty Tier Higher copays, often 25-40% coinsurance Plan benefits summary
Step Therapy May require trying preferred ALK inhibitor first Plan's step therapy list
Quantity Limits 240 capsules per 30 days (standard dosing) Pharmacy benefits section

Prior Authorization Requirements for Alecensa

Blue Cross Blue Shield plans in Pennsylvania require prior authorization for Alecensa through their utilization management vendor, Carelon (formerly AIM Specialty Health). Here's what you need to know:

How to Submit Prior Authorization

For Providers:

  • Phone: 1-800-728-8008 (Monday-Friday, 8 AM-5 PM ET)
  • Online: Carelon Provider Portal via Availity
  • Fax: 1-877-325-5979 (if portal unavailable)

Required Documentation:

  • Complete diagnosis with staging information
  • ALK testing results (IHC/FISH positive)
  • Treatment history and prior therapies
  • Surgical history (for adjuvant therapy)
  • Medical necessity letter from oncologist
Tip: Independence Blue Cross members can also call 1-866-745-1783 for Carelon-specific inquiries.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
Missing ALK test results Submit pathology report showing ALK rearrangement IHC/FISH report with positive ALK status
Insufficient surgical history Provide operative reports and staging Surgery notes, pathology, staging documents
Step therapy not met Request medical exception or show contraindication to preferred agent Medical necessity letter explaining why alternatives aren't suitable
Non-formulary status File formulary exception request Clinical justification for Alecensa vs. alternatives
"Not medically necessary" Cite FDA approval and NCCN guidelines Updated medical necessity letter with guideline references

Step-by-Step Appeals Process

Internal Appeals (First Level)

Timeline: Must be filed within 180 days of denial for most BCBS commercial plans.

Steps:

  1. Gather your denial letter - Note the specific reason code and deadline
  2. Contact your doctor - Request updated medical necessity letter
  3. Submit appeal - Use plan's member portal or mail/fax to appeals department
  4. Include supporting documents - All clinical records, guidelines, studies
  5. Request peer-to-peer review - Ask your oncologist to speak with plan's medical director
  6. Track submission - Keep copies and confirmation receipts
  7. Follow up - Plans typically respond within 30 days for standard appeals

Expedited Appeals

For urgent situations where delays could jeopardize health:

  • Timeline: 72 hours for decision
  • How to request: Call member services and specifically request "expedited appeal"
  • Required: Statement from physician that standard timeline could harm patient

Medical Necessity Documentation

Clinician Corner: Medical Necessity Letter Checklist

Your oncologist's letter should include:

Clinical Information:

  • ✅ Confirmed ALK-positive NSCLC diagnosis with staging
  • ✅ Surgical history and pathology results (for adjuvant use)
  • ✅ Previous treatments tried and outcomes
  • ✅ Contraindications to alternative ALK inhibitors
  • ✅ Expected treatment duration and monitoring plan

Evidence-Based Support:

  • ✅ FDA approval for ALK-positive NSCLC (metastatic and adjuvant)
  • ✅ NCCN Guidelines recommendation for ALK inhibitors
  • ✅ ALINA trial data showing 76% reduction in recurrence risk
  • ✅ Patient-specific factors supporting Alecensa choice

Professional Guidelines:

  • FDA labeling supports both metastatic and adjuvant treatment
  • NCCN Category 1 recommendation for ALK-positive NSCLC
  • ASCO guidelines endorse adjuvant ALK inhibitor therapy

Pennsylvania External Review Program

Pennsylvania launched its Independent External Review Program in January 2024, giving patients a powerful tool to overturn insurance denials. The success rate is impressive: approximately 50% of external reviews result in coverage approval.

How Pennsylvania External Review Works

Eligibility:

  • Must complete internal appeals first
  • Have received "Final Adverse Benefit Determination" letter
  • Request within 4 months of final denial

Process:

  1. File request - Submit online at pa.gov external review portal
  2. Assignment - Pennsylvania Insurance Department assigns Independent Review Organization (IRO)
  3. Submit additional evidence - You have 15 days to provide supporting documents
  4. IRO decision - Standard reviews decided within 45 days; expedited within 72 hours
  5. Binding result - If IRO approves, insurer must provide coverage immediately

Contact Information:

From our advocates: "We've seen several Pennsylvania patients successfully overturn Alecensa denials through the state's external review process. The key is submitting comprehensive clinical documentation that clearly links ALK-positive status to the need for this specific therapy. One patient's external review was approved within 30 days after including updated NCCN guidelines and the ALINA trial results."

Templates & Scripts

Patient Phone Script for Blue Cross Blue Shield

"Hi, I'm calling about prior authorization for Alecensa, prescribed by my oncologist for ALK-positive lung cancer. My member ID is [number]. Can you tell me the current formulary status and what documentation is needed for approval? Also, what's the typical timeline for PA decisions?"

Medical Necessity Letter Template

[Date]
Medical Director
[Insurance Plan Name]
[Address]

RE: Prior Authorization Appeal - Alecensa (alectinib)
Patient: [Name], DOB: [date], Member ID: [number]

Dear Medical Director,

I am requesting coverage approval for Alecensa (alectinib) for [Patient Name], diagnosed with ALK-positive non-small cell lung cancer.

CLINICAL JUSTIFICATION:
• Confirmed ALK rearrangement by [test method, date]
• [Stage/surgical history as applicable]
• Medical necessity based on FDA approval and NCCN Category 1 recommendation
• [Patient-specific factors supporting Alecensa]

SUPPORTING EVIDENCE:
• FDA approval for ALK-positive NSCLC (adjuvant and metastatic settings)
• ALINA trial demonstrating 76% reduction in disease recurrence
• NCCN Guidelines recommend ALK inhibitors as first-line therapy

This treatment is medically necessary and consistent with evidence-based care standards.

Sincerely,
[Physician name, credentials]

Cost Assistance Options

Even with insurance coverage, Alecensa can be expensive. Here are assistance programs:

Manufacturer Support:

  • Genentech Patient Foundation - Income-based assistance
  • Copay card - May reduce out-of-pocket costs for eligible patients
  • Information: Genentech-Access.com

Additional Resources:

  • CancerCare Copay Assistance Foundation - Grants for treatment costs
  • Patient Advocate Foundation - Copay relief program
  • Leukemia & Lymphoma Society - Patient aid program

FAQ

How long does Blue Cross Blue Shield PA take in Pennsylvania? Standard prior authorization decisions are typically made within 15 days for pre-service requests. Expedited reviews are completed within 72 hours when medically urgent.

What if Alecensa is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and that preferred alternatives are inappropriate or contraindicated for your specific situation.

Can I get an expedited appeal if my cancer is progressing? Yes. If your oncologist certifies that delays could seriously jeopardize your health, you can request an expedited appeal with a 72-hour decision timeline.

Does step therapy apply if I'm treatment-naive? Step therapy requirements vary by plan. Some may require trying a preferred ALK inhibitor first, while others allow Alecensa as first-line therapy with proper justification.

What happens if my internal appeal is denied? You can request Pennsylvania's external review within 4 months of the final denial. The state's Independent Review Organization has overturned approximately 50% of denials in its first year.

Can I continue treatment while appealing? If you file an expedited appeal and your doctor certifies that stopping treatment could harm you, some plans will continue coverage pending the appeal decision. Check your specific plan's continuation of benefits policy.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Their platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that align with payers' own criteria, significantly improving approval rates for specialty medications like Alecensa.

For additional support with your Blue Cross Blue Shield appeal, consider reaching out to the Pennsylvania Health Law Project at 1-800-274-3258 if you have Medicaid coverage, or contact Counterforce Health for assistance with commercial insurance appeals.

Sources & Further Reading

This guide provides educational information and should not replace professional medical or legal advice. Always consult with your healthcare provider and insurance plan for personalized guidance. Coverage policies and requirements may change; verify current information with your specific Blue Cross Blue Shield plan.

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