By Counterforce Health Team in Bavencio (avelumab) —

How to Get Bavencio (Avelumab) Covered by Cigna in California: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Bavencio (Avelumab) Covered by Cigna in California

Cigna requires prior authorization for Bavencio (avelumab) in California. Submit the Bavencio PA form via fax (855-840-1678) or online at CoverMyMeds. Include diagnosis (ICD-10), prior platinum therapy records for urothelial cancer, and recent imaging (≤8 weeks). Standard approval takes 5 business days. If denied, file internal appeal within 180 days, then escalate to California's Independent Medical Review (IMR) via DMHC for binding external review.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Required Forms and Documentation
  4. Submission Methods and Portals
  5. Common Denial Reasons and Solutions
  6. Appeals Process in California
  7. California Independent Medical Review (IMR)
  8. Specialty Pharmacy Enrollment
  9. Cost Assistance Options
  10. FAQ

Coverage Requirements at a Glance

Requirement Details Source
Prior Authorization Required for all indications Cigna formulary
Approved Indications Metastatic Merkel cell carcinoma; maintenance urothelial carcinoma PA form
Prescriber Requirements Oncologist or specialist Cigna policy
Age Requirement 18+ years PA form criteria
Performance Status ECOG 0-1 typically required Clinical guidelines
Imaging Recent scans (within 8 weeks) PA documentation
Specialty Pharmacy Dispensed through Accredo Cigna specialty pharmacy

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Gather Documents

Who: Patient or clinic staff
Timeline: 1-2 days
Check your Cigna plan includes specialty drug coverage and gather required documentation.

Documents needed:

  • Cigna insurance card and member ID
  • Pathology report confirming Merkel cell carcinoma or urothelial carcinoma
  • Recent imaging (CT, MRI, or PET scan within 8 weeks)
  • For urothelial cancer: documentation of prior platinum-based chemotherapy
  • ECOG performance status assessment

2. Complete Prior Authorization Form

Who: Prescribing oncologist
Timeline: 30 minutes
Download and complete the Bavencio PA form.

3. Submit Authorization Request

Who: Clinic staff
Timeline: Same day
Submit via online portal (preferred) or fax to 855-840-1678.

4. Track Authorization Status

Who: Patient or clinic
Timeline: Check after 3 business days
Standard review takes 5 business days. Call 800-882-4462 for status updates.

5. Enroll with Accredo Specialty Pharmacy

Who: Patient
Timeline: 1-2 days after approval
Call Accredo at 877-826-7657 to initiate enrollment and coordinate delivery.

Required Forms and Documentation

Primary Form: Bavencio Prior Authorization

The current Bavencio PA form (Version 042522) requires:

Patient Information:

  • Full name, Cigna ID, date of birth, address, phone
  • Office contact information and Tax ID

Clinical Information by Indication:

Metastatic Merkel Cell Carcinoma Urothelial Carcinoma
✓ Confirmed metastatic disease ✓ Locally advanced or metastatic disease
✓ Pathology confirmation ✓ Prior platinum chemotherapy (cisplatin/carboplatin)
✓ Performance status ✓ Disease progression documentation
✓ Maintenance therapy setting

Additional Requirements:

  • ICD-10 diagnosis codes
  • Dosing: 800mg IV every 2 weeks (standard FDA dosing)
  • Site of care details (office, infusion center, home health)
  • Prescriber attestation and signature
Tip: Mark requests as "urgent" if treatment delay could jeopardize the patient's life, health, or ability to regain maximum function. Call 800-882-4462 for urgent requests.

Submission Methods and Portals

Fax Submission

  • Fax Number: 855-840-1678
  • Include completed PA form and all supporting documentation
  • Use cover sheet with patient name and Cigna ID

Response Timeline

  • Standard requests: 5 business days
  • Urgent requests: 72 hours (must call to expedite)
  • California law requirement: Non-urgent PA decisions within 72 hours or auto-approval

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
Insufficient prior therapy documentation (UC) Submit complete chemotherapy records Infusion logs, oncology notes, dates of platinum therapy
Missing performance status Provide recent ECOG assessment Oncology note with ECOG 0-1 documentation
Outdated imaging Submit recent scans Radiology reports within 8 weeks
Non-formulary status Request formulary exception Medical necessity letter, clinical justification
Step therapy not met Document contraindications or failures Prior therapy records, adverse event documentation

Appeals Process in California

Internal Appeals (Required First Step)

Level 1 Appeal:

  • Deadline: 180 days from denial notice
  • Submit to: Cigna appeals department (address on denial letter)
  • Phone: 800-882-4462
  • Timeline: 30 days for standard, 72 hours for expedited
  • Required documents: Denial letter, medical records, physician statement

Level 2 Appeal:

  • Automatic: Triggered if Level 1 denied
  • Deadline: 60 days from Level 1 denial
  • Timeline: 30 days for decision (15 days for urgent)
Note: California law requires Cigna to respond to urgent step therapy override requests within 24 hours and non-urgent requests within 72 hours, with auto-approval if delayed.

Peer-to-Peer Review

Request a peer-to-peer review where your oncologist speaks directly with Cigna's medical director. This often resolves denials faster than written appeals.

To request: Call 800-882-4462 and ask for peer-to-peer review scheduling.

California Independent Medical Review (IMR)

California offers one of the strongest external review processes in the country through the Department of Managed Health Care (DMHC).

When to File IMR

  • After Cigna's final internal denial
  • If Cigna doesn't respond within 30 days
  • For denials based on "not medically necessary" or "experimental/investigational"

How to File IMR

  1. Download application: DMHC IMR forms
  2. Submit within 6 months of final denial
  3. No cost to patient
  4. Contact DMHC Help Center: 888-466-2219

IMR Timeline and Success Rates

  • Standard review: 45 days
  • Expedited review: 7 days (3 days if harm risk)
  • Success rate: 73% of patients receive requested services
  • Binding decision: Cigna must authorize if IMR approves

Specialty Pharmacy Enrollment

Bavencio is dispensed exclusively through Cigna's specialty pharmacy partner, Accredo.

Enrollment Process

  1. Call Accredo: 877-826-7657 (24/7 support)
  2. Benefits verification: Accredo confirms coverage and copay
  3. Financial assistance: Accredo connects patients to manufacturer copay programs
  4. Delivery coordination: Home or provider office delivery
  5. Clinical support: Access to oncology-trained pharmacists and nurses

Required Information

  • Cigna insurance card
  • Prescription from oncologist
  • Delivery address and preferences
  • Emergency contact information

Cost Assistance Options

Manufacturer Support

  • Merck/Pfizer Patient Assistance: Financial assistance for eligible patients
  • Copay cards: May reduce out-of-pocket costs for commercially insured patients
  • Contact: Check with Accredo during enrollment (877-826-7657)

California State Programs

  • Covered California: Subsidies for marketplace plans
  • Medi-Cal: California's expanded Medicaid program
  • HIPP (Health Insurance Premium Payment): Helps pay insurance premiums

FAQ

Q: How long does Cigna prior authorization take for Bavencio in California? A: Standard requests take 5 business days. Urgent requests are processed within 72 hours. California law requires auto-approval if Cigna doesn't respond to non-urgent requests within 72 hours.

Q: What if Bavencio is not on my Cigna formulary? A: Request a formulary exception by submitting a medical necessity letter with your PA. If denied, you can appeal through internal appeals and then California's IMR process.

Q: Can I get expedited review if my cancer is progressing? A: Yes. Your oncologist can request expedited/urgent review by documenting that delay would jeopardize your life, health, or ability to regain maximum function.

Q: What happens if Cigna denies my appeal? A: You can file for Independent Medical Review (IMR) with California's DMHC within 6 months. IMR decisions are binding on Cigna and have a 73% approval rate.

Q: Do I need to use Accredo pharmacy? A: Yes, Bavencio is typically only available through Cigna's specialty pharmacy network, primarily Accredo. They provide specialized handling for this infusion medication.

Q: What if I'm currently getting Bavencio and Cigna suddenly denies coverage? A: File an urgent appeal immediately and request a peer-to-peer review. Your oncologist should document that stopping treatment would cause harm. California law provides additional protections for treatment continuity.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals with evidence-backed strategies. Our platform analyzes denial letters and drafts targeted rebuttals aligned to each plan's specific policies, increasing approval rates for complex medications like Bavencio. Learn more about our appeal assistance services.

When navigating Cigna's prior authorization process, having the right documentation and understanding California's robust patient protection laws can make the difference between approval and denial. Counterforce Health specializes in helping patients and providers build compelling cases that address payer-specific requirements and leverage state appeal rights effectively.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan and individual circumstances. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For assistance with insurance appeals or coverage questions, contact the California Department of Managed Health Care Help Center at 888-466-2219.

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