By Counterforce Health Team in Bavencio (avelumab) —

How to Get Bavencio (Avelumab) Covered by Blue Cross Blue Shield in North Carolina: Complete Appeals Guide with Forms and Timelines

Answer Box: Getting Bavencio Covered by Blue Cross Blue Shield in North Carolina

Bavencio (avelumab) requires prior authorization from Blue Cross Blue Shield of North Carolina for both Merkel cell carcinoma and urothelial carcinoma. Submit clinical documentation through the Blue Cross NC provider portal before treatment. If denied, you have two internal appeal levels, then external review through North Carolina's Smart NC program within 120 days. For urgent cases, expedited appeals can get decisions within 72 hours.

First step today: Call Blue Cross NC member services to confirm your specific plan's PA requirements and get the denial reason in writing if already denied.

Table of Contents

  1. Understanding Your Blue Cross NC Coverage
  2. Prior Authorization Requirements
  3. Common Denial Reasons and How to Fix Them
  4. Step-by-Step Appeals Process
  5. Smart NC External Review
  6. Appeal Letter Templates
  7. Cost Assistance Options
  8. FAQ

Understanding Your Blue Cross NC Coverage

Blue Cross Blue Shield of North Carolina covers Bavencio (avelumab) under medical benefits, not pharmacy benefits, since it's administered as an IV infusion. This means the drug is covered when given in a clinical setting like an oncology clinic or hospital outpatient department.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required before treatment Blue Cross NC PA lookup
FDA-Approved Uses Merkel cell carcinoma, urothelial carcinoma maintenance FDA prescribing information
Site of Care Outpatient infusion center or hospital Blue Cross NC medical policy
Appeals Deadline 180 days for commercial plans Plan documents

Counterforce Health helps patients and clinicians navigate complex prior authorization requirements like these, turning insurance denials into targeted, evidence-backed appeals that align with each payer's specific criteria.

Prior Authorization Requirements

Blue Cross NC requires prior authorization for Bavencio as of July 2024, consistent with their expanded specialty drug policies. The authorization process involves clinical review to ensure medical necessity.

Required Documentation

Your oncologist must submit:

  • Diagnosis confirmation with ICD-10 codes (C44.10-C44.19 for Merkel cell carcinoma, C67.9 for bladder cancer)
  • Staging information and imaging results
  • Prior treatment history including platinum-based chemotherapy for urothelial carcinoma
  • Treatment plan with dosing (10 mg/kg IV every 2 weeks)
  • Clinical notes supporting medical necessity

Submission Process

  1. Check current requirements using the Blue Cross NC provider portal
  2. Submit online through the secure provider system or via fax (verify current fax number with customer service)
  3. Allow 5-10 business days for standard review
  4. Request expedited review if treatment delay would cause serious harm
Tip: Submit PA requests at least 2 weeks before planned treatment start date to avoid delays.

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn Required Evidence
"Not medically necessary" Submit NCCN guidelines showing Category 1 recommendation NCCN Urothelial Carcinoma Guidelines
"Experimental/investigational" Provide FDA approval letter and prescribing information FDA approval documentation
Missing prior therapy documentation Submit records of platinum-based chemotherapy Clinic notes, infusion records
Wrong diagnosis code Verify ICD-10 codes match FDA-approved indications Pathology reports, staging documents

From Our Advocates

We've seen cases where initial Bavencio denials were overturned simply by including the specific NCCN guideline page showing Category 1 recommendation for maintenance therapy. Payers often approve when they see the treatment aligns with established clinical pathways, even if the initial request lacked this context.

Step-by-Step Appeals Process

Level 1: Internal Appeal

Timeline: Must file within 180 days of denial notice
Decision timeframe: 30 days for standard, 72 hours for expedited
Who files: Patient or authorized representative (physician, family member)

  1. Get the denial letter - Note the specific reason code and reference number
  2. Gather supporting documents - Clinical notes, imaging, lab results, prior therapy records
  3. Write appeal letter (see template below) addressing each denial reason point-by-point
  4. Submit via multiple channels - Fax, mail, and online portal for tracking
  5. Follow up within 10 business days if no acknowledgment received

Level 2: Second Internal Appeal

If Level 1 is denied, you can request a second internal review within 60 days. This typically involves a different reviewer and may include a peer-to-peer discussion between your oncologist and the plan's medical director.

Peer-to-Peer Review

Request a peer-to-peer call when appealing clinical necessity denials. Your oncologist can speak directly with Blue Cross NC's reviewing physician to discuss:

  • Patient's specific clinical situation
  • Why Bavencio is the most appropriate treatment
  • How it aligns with NCCN guidelines
  • Previous treatment failures or contraindications

Smart NC External Review

If both internal appeals are denied, North Carolina's Smart NC program offers binding external review through the Department of Insurance.

Eligibility and Process

  • Who qualifies: State-regulated insurance plans (not self-funded ERISA plans)
  • When to file: Within 120 days of final internal denial
  • Timeline: 45 days for standard review, 72 hours for expedited
  • Cost: Free to patients

How to Request External Review

  1. Call Smart NC: 1-855-408-1212 for guidance
  2. Submit written request to NC Department of Insurance
  3. Include all documentation: Denial letters, medical records, clinical guidelines
  4. State urgency if requesting expedited review for cancer treatment

The external review decision is binding - if approved, Blue Cross NC must cover the treatment within 3 business days.

Appeal Letter Templates

Medical Necessity Letter Template

[Date]

Blue Cross Blue Shield of North Carolina
Appeals Department
[Address from denial letter]

Re: Appeal for Bavencio (avelumab) Coverage
Member: [Patient Name]
ID: [Member ID]
Case #: [Reference number from denial]

Dear Appeals Reviewer,

I am writing to appeal the denial of coverage for Bavencio (avelumab) for my patient [Name], who has [metastatic Merkel cell carcinoma/locally advanced urothelial carcinoma].

CLINICAL RATIONALE:
[Patient Name] has been diagnosed with [specific diagnosis] confirmed by [pathology/imaging]. Previous treatments include [list prior therapies and outcomes]. Bavencio is FDA-approved for this indication and represents the standard of care per NCCN Guidelines (Category 1 recommendation).

MEDICAL NECESSITY:
• FDA-approved indication: [cite specific approval]
• NCCN Guidelines recommendation: Category 1 for [indication]
• No contraindications to treatment
• Expected to improve progression-free survival based on clinical trial data

I have attached comprehensive medical records supporting this request and am available for peer-to-peer review at your convenience.

Sincerely,
[Physician signature and credentials]

Patient Phone Script

When calling Blue Cross NC member services:

"I'm calling about a denial for Bavencio, also called avelumab, for cancer treatment. Can you please tell me the specific reason for denial and what documentation is needed for an appeal? I'd also like to know the deadline for filing an appeal and whether expedited review is available given the urgent nature of cancer treatment."

Cost Assistance Options

If coverage challenges persist, several assistance programs can help:

Manufacturer Support

  • Bavencio Co-pay Program: May reduce out-of-pocket costs for eligible patients
  • Patient assistance programs: Income-based support through EMD Serono and Pfizer

Foundation Grants

  • Patient Access Network (PAN) Foundation: Provides grants for cancer treatment
  • CancerCare Co-Payment Assistance: Helps with insurance premiums and co-pays

State Resources

  • North Carolina 211: Dial 211 for local assistance program information
  • Smart NC: Can provide guidance on insurance appeals and coverage options

Counterforce Health specializes in turning insurance denials into successful appeals by identifying the specific denial basis and crafting point-by-point rebuttals aligned with each payer's requirements, helping patients access critical medications like Bavencio.

FAQ

How long does Blue Cross NC prior authorization take?
Standard PA decisions are made within 5-10 business days. Expedited reviews for urgent cancer cases can be completed within 24-72 hours.

What if Bavencio isn't on my formulary?
Since Bavencio is covered under medical benefits (not pharmacy), formulary status typically doesn't apply. Coverage is based on medical necessity and FDA-approved indications.

Can I get an expedited appeal in North Carolina?
Yes, both Blue Cross NC and Smart NC offer expedited appeals when treatment delays would seriously jeopardize your health. Cancer treatments typically qualify.

What happens if Smart NC external review is denied?
The external review decision is final for the administrative process. You may still have legal options or can explore alternative treatments and assistance programs.

Does step therapy apply to Bavencio?
For urothelial carcinoma maintenance therapy, you must have completed first-line platinum-based chemotherapy without disease progression. For Merkel cell carcinoma, step therapy typically doesn't apply as it's often first-line treatment.

How do I know if my plan is state-regulated for external review?
Most individual and small group plans purchased in North Carolina are state-regulated. Large employer "self-funded" plans typically are not. Contact Smart NC at 1-855-408-1212 to verify eligibility.

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 plan for personalized guidance. For assistance with insurance appeals and coverage determinations, contact Counterforce Health or North Carolina's Smart NC program at 1-855-408-1212.

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