By Counterforce Health Team in Breyanzi (lisocabtagene maraleucel) —

How to Get Breyanzi Covered by Blue Cross Blue Shield of Michigan: Prior Authorization Guide and Appeals Process

Answer Box: Getting Breyanzi Covered in Michigan

Blue Cross Blue Shield of Michigan requires prior authorization for Breyanzi (lisocabtagene maraleucel) under their medical benefit, with coverage limited to FDA-approved indications after documented failure of prior therapies. Submit requests using the BCBSM Medication Authorization Request Form (fax to 1-877-325-5979), including cardiac function tests (EF ≥50%), infection screens, and complete treatment history. If denied, Michigan patients have 127 days to file external review with DIFS.

First step today: Verify your specific BCBS Michigan plan type and gather prior therapy documentation before submitting PA.

Table of Contents

  1. Plan Types & Coverage Implications
  2. Formulary Status & Medical Necessity
  3. Prior Authorization Requirements
  4. Step-by-Step: Fastest Path to Approval
  5. Common Denial Reasons & Solutions
  6. Appeals Process in Michigan
  7. Cost Considerations & Support Programs
  8. When to Escalate
  9. FAQ

Plan Types & Coverage Implications

Blue Cross Blue Shield of Michigan operates several plan types that affect Breyanzi coverage:

Commercial Plans

  • Blue Cross PPO/HMO: Standard prior authorization through medical benefit
  • Simply Blue: Limited network may restrict CAR-T treatment centers
  • Self-funded employer groups: May have different PA criteria

Medicare Plans

  • Medicare Plus Blue: Uses separate Medicare PA requirements
  • BCN Advantage: Subject to Medicare guidelines plus BCBS Michigan policies

Network Considerations

CAR-T therapy requires treatment at certified centers within BCBS Michigan's network. Breyanzi must be administered through Bristol Myers Squibb's Cell Therapy Network at qualified facilities.

Formulary Status & Medical Necessity

Coverage Position

Breyanzi is covered under BCBS Michigan's medical benefit (not pharmacy benefit) as a specialty oncology agent requiring prior authorization. It's classified as a high-cost therapy subject to utilization management.

FDA-Approved Indications Covered

  • Large B-cell lymphoma (LBCL): Adults after ≥2 prior systemic therapies
  • Chronic lymphocytic leukemia (CLL/SLL): Adults after ≥2 prior lines including BTK inhibitor and BCL-2 inhibitor

Medical Necessity Exclusions

BCBS Michigan will deny coverage if any of these apply:

  • Cardiac ejection fraction <50%
  • Active uncontrolled infection
  • Grade 2-4 graft-versus-host disease
  • Allogeneic cellular therapy within 6 weeks
  • Concomitant genetic syndromes (except Down syndrome)

Prior Authorization Requirements

Required Documentation

Requirement Details Source
Diagnosis confirmation Pathology report with specific LBCL or CLL subtype FDA labeling requirement
Prior therapy history Complete list with dates, responses, reasons for discontinuation BCBS Michigan PA criteria
Cardiac assessment Echo or MUGA showing EF ≥50% Medical necessity criteria
Infection screening Recent labs ruling out active hepatitis B/C, HIV, fungal infections Safety requirements
Performance status ECOG score and functional assessment Clinical evaluation

Submission Process

  • Form: Use BCBSM Medication Authorization Request Form
  • Fax: 1-877-325-5979
  • Timeline: Standard review takes 5-10 business days
  • Expedited: Available for urgent cases with physician attestation

Step-by-Step: Fastest Path to Approval

1. Verify Plan Participation

Who: Patient or clinic staff
Action: Confirm member ID and specific BCBS Michigan plan type
Timeline: Same day
Tool: BCBS Michigan member portal

2. Gather Clinical Documentation

Who: Healthcare team
Action: Collect pathology, imaging, prior therapy records, cardiac function, labs
Timeline: 1-2 days
Checklist: Use medical necessity requirements above

3. Complete Prior Authorization

Who: Prescribing physician or authorized staff
Action: Submit comprehensive PA with all supporting documents
Timeline: 1 day to submit
Form: BCBSM Medication Authorization Request Form

4. Monitor for Decision

Who: Clinic staff
Action: Track PA status and respond to any requests for additional information
Timeline: 5-10 business days for standard review
Contact: BCBS Michigan provider services

5. Schedule Treatment (if approved)

Who: CAR-T center coordinator
Action: Coordinate leukapheresis and manufacturing timeline
Timeline: 3-4 weeks from approval
Requirement: Treatment at Bristol Myers Squibb Cell Therapy Network site

Clinician Corner: Medical Necessity Letter

Your medical necessity letter should include:

  • Problem statement: Specific LBCL or CLL diagnosis with staging
  • Prior treatments: Detailed history with dates, doses, responses, and reasons for discontinuation
  • Clinical rationale: Why Breyanzi is appropriate at this line of therapy
  • Guideline support: Reference to NCCN guidelines or FDA labeling
  • Contraindications: Documentation that patient lacks exclusion criteria
  • Treatment plan: Proposed schedule, monitoring, and site of care
Tip: Include specific ICD-10 codes and reference current NCCN or ASH guidelines to strengthen medical necessity arguments.

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
Insufficient prior therapies Document all previous regimens with dates and outcomes Pharmacy records, infusion logs, physician notes
Missing cardiac assessment Obtain recent echo or MUGA Cardiology report showing EF ≥50%
Active infection concern Provide current lab results Recent CBC, hepatitis panel, HIV test
Not at certified center Transfer care to approved CAR-T facility Referral to Bristol Myers Squibb Cell Therapy Network site
Step therapy not met Document failure/intolerance of required prior agents Treatment records showing progression or toxicity

Appeals Process in Michigan

Internal Appeal (First Level)

  • Timeline: Must file within 180 days of denial
  • Process: Submit additional clinical documentation
  • Decision: 30 days for standard, 72 hours for urgent
  • Contact: BCBS Michigan member services

External Review (Michigan DIFS)

Expedited Appeals

Available when delay would:

  • Seriously jeopardize patient's health
  • Impair ability to regain maximum function
  • Subject patient to severe pain

Requirement: Physician letter documenting urgency

Cost Considerations & Support Programs

Breyanzi Pricing

  • List price: ~$447,000-$487,000 per treatment
  • Total cost: Can exceed $500,000 including hospitalization and supportive care

Financial Assistance

  • Bristol Myers Squibb Patient Assistance: Access Support
  • Manufacturer copay programs: May reduce out-of-pocket costs for eligible patients
  • Foundation grants: Organizations like Leukemia & Lymphoma Society offer financial support

Insurance Coverage

Most BCBS Michigan plans cover 80-90% of costs after deductible for in-network providers. Verify specific benefits before treatment.

When to Escalate

Contact Michigan regulators if:

  • BCBS Michigan fails to respond within required timeframes
  • Denial appears to contradict FDA labeling or medical guidelines
  • Process violations occur during appeals

Michigan Department of Insurance and Financial Services
Phone: 877-999-6442
Website: michigan.gov/difs

FAQ

How long does BCBS Michigan prior authorization take?

Standard PA review takes 5-10 business days. Expedited reviews for urgent cases are completed within 72 hours.

What if Breyanzi is denied as "not medically necessary"?

File an internal appeal with additional clinical documentation emphasizing FDA-approved indications and guideline support. If denied again, request external review through Michigan DIFS.

Can I get Breyanzi covered if I haven't tried all standard therapies?

BCBS Michigan typically requires documented failure of appropriate prior therapies per FDA labeling. Medical exceptions may apply for contraindications or urgent clinical circumstances.

Does step therapy apply to CAR-T therapy?

Yes, BCBS Michigan uses step therapy requirements for oncology drugs, though specific algorithms aren't publicly detailed. Document all prior standard treatments and their outcomes.

What if my CAR-T center isn't in BCBS Michigan's network?

You may need to transfer care to an in-network facility or request a network exception. Out-of-network treatment typically requires pre-authorization and may have higher costs.

How do I request an expedited appeal in Michigan?

Submit a physician letter documenting that delay would seriously jeopardize your health, along with your appeal. Both internal and external appeals can be expedited.

What happens if DIFS overturns BCBS Michigan's denial?

The decision is binding. BCBS Michigan must provide coverage as directed by the external review organization.

Are there alternatives if Breyanzi is denied?

Other CAR-T therapies like Yescarta or Kymriah may be options, though they have similar PA requirements. Your oncologist can discuss alternative treatment approaches.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex insurance approvals by turning denials into evidence-backed appeals. Their platform analyzes denial letters and payer policies to create targeted rebuttals that align with each plan's specific requirements, improving approval rates for specialty medications like CAR-T therapies.

When facing a Breyanzi denial from BCBS Michigan, having expert support can make the difference between approval and prolonged treatment delays. Counterforce Health specializes in crafting appeals that address payer-specific criteria while incorporating the clinical evidence and procedural requirements that Michigan's external review process demands.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with BCBS Michigan directly and consult with your healthcare team about treatment decisions. For personalized assistance with insurance appeals, consider consulting with healthcare advocates or legal professionals experienced in insurance coverage issues.

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