By Counterforce Health Team in Breyanzi (lisocabtagene maraleucel) —

How to Get Breyanzi Covered by UnitedHealthcare in Ohio: Complete Prior Authorization Guide (2025)

Answer Box: Your Fastest Path to Breyanzi Coverage

Breyanzi (lisocabtagene maraleucel) requires prior authorization from UnitedHealthcare in Ohio. Your oncologist must submit clinical documentation showing you meet FDA-approved criteria for relapsed/refractory large B-cell lymphoma (≥2 prior lines) or CLL/SLL (after BTK and BCL-2 inhibitor failure). Standard review takes 72 hours; expedited review 24 hours for urgent cases.

First step today: Contact your treatment center to confirm they're UnitedHealthcare credentialed for CAR-T therapy and ask them to begin the PA submission through the UnitedHealthcare Provider Portal.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timing and Deadlines
  4. Medical Necessity Criteria
  5. Cost Considerations
  6. Denials and Appeals
  7. Specialty Pharmacy Requirements
  8. Ohio-Specific Appeal Rights
  9. Common Questions
  10. Resources and Next Steps

Coverage Basics

Is Breyanzi Covered by UnitedHealthcare?

Yes, Breyanzi is covered under UnitedHealthcare's oncology medication policy when medically necessary and administered at certified treatment centers. Coverage applies across commercial plans, Medicare Advantage, and Medicaid managed care in Ohio.

Which UnitedHealthcare Plans Cover Breyanzi?

  • Commercial/Employer Plans: Covered with prior authorization
  • Medicare Advantage: Follows Medicare NCD 110.24 for CAR-T therapies
  • Medicaid Managed Care: Covered under transplantation services benefit
  • Exchange/Marketplace Plans: Prior authorization required
Note: Self-funded employer plans may have different requirements. Check with your HR benefits team about your specific coverage.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Confirm Treatment Center Credentialing (Day 1)
    • Use the Breyanzi treatment center locator to find certified centers in Ohio
    • Verify the center is in UnitedHealthcare's specialty network
    • Confirm they can handle CAR-T REMS requirements
  2. Gather Required Documentation (Days 1-2)
    • Complete medical records showing disease progression
    • Laboratory values (CBC, CMP, liver function)
    • Cardiac function assessment (ECHO or MUGA)
    • Documentation of prior therapy failures
  3. Submit Prior Authorization (Day 3)
  4. Track Status (Days 4-5)
    • Check portal for status updates
    • Respond to any information requests within 24-48 hours

Who Submits the Prior Authorization?

Your oncologist or treatment center submits the PA request—patients cannot submit directly. However, you can:

  • Ask your provider about submission status
  • Request expedited review if medically urgent
  • Provide additional clinical information if requested

Timing and Deadlines

Standard Review Timeline

Review Type Timeline When to Use
Standard PA 72 hours Non-urgent cases
Expedited PA 24 hours Urgent medical need
Additional info response 14 days given, 24-48 hours recommended Information requests

When to Request Expedited Review

Request expedited review when:

  • Disease progression threatens immediate health
  • Delay could compromise treatment effectiveness
  • Patient's condition is rapidly deteriorating
Tip: Include specific clinical reasoning for urgency in your expedited request—general statements aren't sufficient.

Medical Necessity Criteria

Coverage at a Glance

Requirement LBCL Criteria CLL/SLL Criteria Documentation Needed
Line of therapy ≥2 prior systemic therapies ≥2 prior lines including BTK + BCL-2 inhibitors Treatment history, dates, responses
Disease status Relapsed or refractory Relapsed or refractory Imaging, labs showing progression
Performance status ECOG 0-2 (typical) ECOG 0-2 (typical) Provider assessment
Organ function Adequate cardiac, hepatic, renal Adequate cardiac, hepatic, renal Recent lab values, ECHO/MUGA
Facility requirement REMS-certified center REMS-certified center Center credentialing verification

Clinician Corner: Medical Necessity Letter Checklist

Healthcare providers should include:

Clinical Documentation:

  • Primary diagnosis with ICD-10 codes
  • Complete treatment history with dates, drugs, doses, and outcomes
  • Evidence of refractoriness or relapse within 12 months of first-line therapy
  • Current disease status with recent imaging/labs

Supporting Evidence:

  • FDA-approved labeling for Breyanzi indications
  • NCCN Guidelines supporting CAR-T use in relapsed/refractory setting
  • Patient-specific factors supporting treatment choice

Cost Considerations

Understanding Your Out-of-Pocket Costs

Breyanzi's wholesale acquisition cost ranges from $447,000 to $487,000, with total treatment costs potentially exceeding $800,000 when including:

  • Pre-treatment workup and lymphodepletion
  • Inpatient monitoring for toxicity management
  • Post-treatment supportive care

Financial Assistance Options

Manufacturer Support:

  • Bristol Myers Squibb Access Support provides patient assistance programs
  • Contact: Visit breyanzi.com for current program details

Foundation Grants:

  • Leukemia & Lymphoma Society Patient Aid Program
  • CancerCare Financial Assistance Program
  • HealthWell Foundation (when funds available)
Important: Apply for financial assistance programs early—many have limited annual funding.

Denials and Appeals

Common Denial Reasons & How to Overturn Them

Denial Reason How to Address Required Documentation
Insufficient prior therapy Document all previous treatments with dates and outcomes Complete treatment timeline, provider notes
Performance status concerns Provide current ECOG assessment with clinical justification Recent clinic visit notes, functional status evaluation
Non-credentialed facility Transfer to certified CAR-T center Confirmation of REMS certification
Missing laboratory values Submit current labs within normal ranges CBC, CMP, LFTs dated within 30 days

Appeals Playbook for UnitedHealthcare in Ohio

Internal Appeals Process:

  1. First Level Internal Appeal
    • File within 180 days of denial
    • Submit through UnitedHealthcare Provider Portal or mail to address on denial letter
    • Include point-by-point response to denial reasons
    • Timeline: 30 days for standard, 72 hours for expedited
  2. Second Level Internal Appeal (if needed)
    • Automatic if first level upheld
    • Independent medical review
    • Timeline: 30 days for standard, 72 hours for expedited

Ohio External Review Process: After exhausting internal appeals, you have the right to external review through the Ohio Department of Insurance:

  • File within: 180 days of final internal denial
  • Process: Independent Review Organization (IRO) conducts medical review
  • Timeline: 30 days standard, 72 hours expedited
  • Decision: Binding on UnitedHealthcare
  • Contact: Ohio DOI Consumer Services at 1-800-686-1526

Specialty Pharmacy Requirements

Why Breyanzi Requires Special Handling

Breyanzi is only available through:

  • REMS-certified treatment centers
  • Facilities credentialed for CAR-T administration
  • Centers with trained staff for managing cytokine release syndrome

Counterforce Health helps patients navigate complex specialty pharmacy requirements by identifying the right treatment centers and ensuring all documentation meets payer-specific criteria for approval.

Finding Certified Centers in Ohio

Use the official Breyanzi treatment center locator to identify certified facilities. Major academic medical centers in Ohio typically offer CAR-T programs, but verify:

  • UnitedHealthcare network participation
  • Current REMS certification status
  • Availability for your treatment timeline

Ohio-Specific Appeal Rights

What Makes Ohio Different

Ohio provides strong consumer protections for insurance appeals:

Extended Timeline: You have 180 days (6 months) to request external review—longer than many states

Independent Determination: Even if UnitedHealthcare claims your case isn't eligible for external review, the Ohio Department of Insurance can independently determine eligibility

Binding Decisions: External review decisions are binding on your insurer—if approved, UnitedHealthcare must cover the treatment

Getting Help in Ohio

  • Ohio Department of Insurance Consumer Services: 1-800-686-1526
  • UHCAN Ohio (Universal Health Care Action Network): Provides consumer assistance with appeals
  • OSHIIP (Ohio Senior Health Insurance Information Program): For Medicare-related issues

Common Questions

How long does UnitedHealthcare PA take in Ohio? Standard review is 72 hours from complete submission. Expedited review for urgent cases is 24 hours. Additional information requests extend the timeline.

What if Breyanzi is non-formulary on my plan? Breyanzi coverage is typically evaluated under medical benefits rather than pharmacy formulary. Your provider can request a medical necessity review regardless of formulary status.

Can I request an expedited appeal? Yes, if delay would seriously jeopardize your health or ability to regain maximum function. Include specific clinical reasoning for urgency.

Does step therapy apply if I've tried treatments outside Ohio? Yes, UnitedHealthcare recognizes prior therapies regardless of where they were administered. Provide complete documentation of all previous treatments.

What happens if my treatment center isn't in-network? Request a network adequacy exception if no in-network certified CAR-T centers are available within a reasonable distance. UnitedHealthcare may authorize out-of-network treatment at in-network rates.

Resources and Next Steps

Immediate Action Items

  1. Contact your oncologist to discuss Breyanzi eligibility and begin PA process
  2. Verify treatment center network status and REMS certification
  3. Gather documentation of prior therapies and current disease status
  4. Apply for financial assistance programs while PA is pending

Key Contacts

  • UnitedHealthcare Provider Services: Use provider portal or call number on your insurance card
  • OptumRx Prior Authorization: 888-397-8129
  • Ohio Department of Insurance: 1-800-686-1526
  • Breyanzi Treatment Center Locator: breyanzi.com/find-a-treatment-center
From Our Advocates: We've seen patients successfully appeal Breyanzi denials by providing comprehensive documentation of treatment failures and working closely with certified CAR-T centers to address specific payer concerns. The key is thorough preparation and persistence through the appeals process.

At Counterforce Health, we specialize in turning insurance denials into targeted, evidence-backed appeals. Our platform helps patients and clinicians navigate complex prior authorization requirements by identifying specific denial reasons and drafting point-by-point rebuttals aligned with payer policies.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances and plan terms. Always consult with your healthcare provider and insurance company for personalized guidance. For questions about Ohio insurance regulations, contact the Ohio Department of Insurance at 1-800-686-1526.

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