By Counterforce Health Team in Kymriah (tisagenlecleucel) —

How to Get Kymriah Covered by Blue Cross Blue Shield in New Jersey: Complete PA Guide with Forms and Appeal Scripts

Quick Start: Get Kymriah Covered by Blue Cross Blue Shield in New Jersey

Getting Kymriah (tisagenlecleucel) covered by Horizon Blue Cross Blue Shield of New Jersey requires prior authorization through their medical policy CC-06005. Your oncologist must document CD19-positive B-cell ALL or eligible lymphoma, failed prior therapies, and treatment at a certified NJ center (Rutgers Cancer Institute or John Theurer Cancer Center). Submit complete medical records via the provider portal or Prime Therapeutics. If denied, file internal appeals within 180 days, then external review through New Jersey's IHCAP program (administered by Maximus Federal Services) with a 66% success rate for provider appeals.

First step today: Contact your oncologist to confirm eligibility criteria and begin gathering documentation for the PA request.

Table of Contents

What This Guide Covers

This guide helps patients and families navigate Kymriah (tisagenlecleucel) coverage with Blue Cross Blue Shield plans in New Jersey, specifically Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ). Kymriah is a CAR-T cell therapy that costs approximately $475,000 for ALL treatment and $373,000 for lymphoma treatment, making prior authorization essential.

Who this helps:

  • Patients with CD19-positive B-cell acute lymphoblastic leukemia (ALL) age 25 or younger
  • Adults with relapsed/refractory diffuse large B-cell lymphoma (DLBCL) or follicular lymphoma
  • Families working with oncologists at certified New Jersey treatment centers
  • Anyone facing a Kymriah denial from Horizon BCBSNJ

Counterforce Health helps patients and clinicians turn insurance denials into successful appeals by creating evidence-backed prior authorization requests and appeal letters that address specific payer criteria and denial reasons.

Before You Start: Verify Your Coverage

Check Your Plan Type

Confirm your specific Blue Cross Blue Shield plan in New Jersey:

  • Horizon Blue Cross Blue Shield of New Jersey (most common NJ BCBS plan)
  • Individual marketplace plans through Horizon
  • Medicare Advantage plans (different appeal rules apply)
  • Employer-sponsored plans (may have different formularies)
Tip: Call the member services number on your insurance card (1-800-355-BLUE for Horizon) to confirm your plan type and verify Kymriah is covered under your specific policy.

Verify Network Status

Kymriah can only be administered at certified treatment centers in New Jersey:

Center Location Network Status Contact
Rutgers Cancer Institute of New Jersey New Brunswick, NJ Check with Horizon BCBSNJ 732-235-2113
John Theurer Cancer Center (Hackensack University Medical Center) Hackensack, NJ Check with Horizon BCBSNJ Verify via hackensackumc.org

Both centers are FACT-accredited and FDA-authorized for Kymriah administration.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all Kymriah treatments Horizon PA Medicine List Horizon BCBSNJ
CD19-Positive Disease Confirmed by pathology/flow cytometry Medical records, pathology reports Medical Policy CC-06005
Age Limits (ALL) 25 years or younger at time of treatment Birth certificate, medical records Medical Policy CC-06005
Certified Center REMS-certified facility only Center verification documents FDA REMS Program
No Active Infections Grade 2+ infections requiring IV antimicrobials excluded Recent lab results, infection workup Medical Policy CC-06005

Gather Required Documentation

Essential Medical Records

For B-cell ALL (age ≤25):

  • Pathology report confirming CD19-positive B-cell ALL
  • Bone marrow biopsy showing >5% lymphoblasts
  • Documentation of relapsed or refractory disease
  • Prior treatment history with dates and outcomes
  • Current infection screening (negative for Grade 2+ infections)
  • Organ function tests (cardiac, pulmonary, renal, hepatic)

For DLBCL/Follicular Lymphoma (adults):

  • Pathology confirming CD19-positive disease
  • Documentation of ≥2 prior treatment failures
  • Imaging showing progressive disease
  • Performance status assessment
  • Bridging therapy plan (if applicable)

Required Clinical Documentation

  1. ICD-10 Diagnosis Codes (verify with your oncologist)
  2. Prior therapy documentation with specific dates, drug names, and reasons for discontinuation
  3. Contraindications to alternative therapies (if applicable)
  4. Laboratory results within 30 days
  5. Imaging studies showing disease status
Note: Horizon BCBSNJ requires documentation that the patient meets ALL criteria in their medical policy. Missing any single requirement can result in denial.

Submit Your Prior Authorization Request

Step 1: Obtain the Correct Forms

Your oncologist will need to submit the prior authorization through:

  • Prime Therapeutics (Horizon's pharmacy benefit manager)
  • Horizon provider portal for medical benefits
  • Direct submission to Horizon medical management

Contact Horizon at 1-800-682-9094 to confirm the current submission process and obtain necessary forms.

Step 2: Complete the Request Packet

Required components:

  1. Completed prior authorization form
  2. Medical necessity letter from oncologist
  3. Complete medical records (last 12 months)
  4. Pathology/lab reports confirming diagnosis
  5. Prior treatment documentation
  6. Treatment center certification documents

Step 3: Medical Necessity Letter Checklist

Your oncologist should include:

  • Patient diagnosis with ICD-10 codes
  • Disease characteristics (CD19 status, staging)
  • Prior treatments with specific outcomes/failures
  • Clinical rationale for Kymriah specifically
  • References to FDA labeling and NCCN Guidelines
  • Treatment center qualifications
  • Monitoring plan for side effects

Follow-Up and Timelines

Expected Review Timeline

Review Type Timeline Notes
Standard Review 5-15 business days Most common for Kymriah
Expedited Review 24-72 hours Requires clinical justification
Additional Information 5 business days to respond Clock stops until info received

Follow-Up Script for Patients

"Hi, I'm calling to check on the status of prior authorization request #[reference number] for Kymriah (tisagenlecleucel) submitted on [date]. Can you tell me if any additional information is needed and when I can expect a decision?"

Document: Date, time, representative name, and reference numbers for all calls.

If You Need More Information

Common requests from Horizon BCBSNJ:

  • Additional lab results (recent CBC, comprehensive metabolic panel)
  • Cardiac function assessment (ECHO or MUGA scan)
  • Infection screening (blood cultures, viral panels)
  • Prior therapy details (specific drug names, doses, duration)
  • Treatment center verification (REMS certification documents)

Response strategy: Submit requested information within the specified deadline (typically 5 business days) to avoid automatic denial.

If Your Request is Denied

Common Denial Reasons and Solutions

Denial Reason How to Address Required Documentation
"Not medically necessary" Medical necessity letter citing FDA approval Oncologist letter, FDA labeling, NCCN Guidelines
"Missing prior therapy documentation" Complete treatment history Medical records, pharmacy records, physician notes
"Not at certified center" Verify center credentials REMS certification, FACT accreditation
"Insufficient organ function" Updated assessments Recent ECHO, PFTs, lab results

Request a Peer-to-Peer Review

Your oncologist can request a direct conversation with Horizon's medical director:

Script for providers: "I'm requesting a peer-to-peer review for [patient name] regarding the denial of Kymriah (tisagenlecleucel). This patient meets all criteria in your medical policy CC-06005, and I'd like to discuss the clinical rationale directly."

Appeals Process in New Jersey

Internal Appeals (Required First Step)

Timeline: File within 180 days of denial How to file:

  • Online via Horizon member portal
  • Phone: 1-800-355-BLUE
  • Mail to address on denial letter

Required documents:

  • Original denial letter
  • Medical necessity letter from oncologist
  • Any additional supporting documentation
  • Completed appeal form

External Review Through IHCAP

New Jersey's Independent Health Care Appeals Program (IHCAP) offers free external review after internal appeals are exhausted.

Key details:

  • Administrator: Maximus Federal Services
  • Success rate: Approximately 66% for provider appeals
  • Timeline: 5 business days for preliminary review, up to 45 days for final decision
  • Expedited option: Available for urgent cases (48-hour decision)

How to file:

  1. Online: https://njihcap.maximus.com
  2. Phone: 1-888-866-6205
  3. Email: [email protected]
From our advocates: We've seen cases where patients initially denied for "experimental" reasons succeeded at external review when their oncologist provided detailed letters explaining how Kymriah is FDA-approved standard of care for their specific condition, along with peer-reviewed evidence of efficacy. The key is addressing the exact denial reason with clinical evidence.

Required for External Appeal

  • Completed external appeal application
  • All internal appeal denial letters
  • Medical records and physician statements
  • Authorization for medical records release
  • Supporting clinical literature (if applicable)

Contact for assistance: NJ Department of Banking and Insurance Consumer Hotline: 1-800-446-7467

Costs and Financial Assistance

Expected Costs

  • Kymriah list price: ~$475,000 (ALL) or ~$373,000 (DLBCL)
  • Additional costs: Hospital stay, monitoring, supportive care
  • Patient responsibility: Varies by plan (typically high-tier specialty drug)

Financial Assistance Options

  1. Novartis Patient Assistance: Contact 1-888-805-4555
  2. Horizon cost-share programs: May reduce copay to $0-$35
  3. State assistance programs: Contact NJ Department of Human Services
  4. Foundation grants: Leukemia & Lymphoma Society, other patient advocacy organizations

Counterforce Health can help identify all available financial assistance options and ensure your appeal addresses both medical necessity and financial hardship considerations.

FAQ

Q: How long does Horizon BCBSNJ prior authorization take for Kymriah? A: Standard review takes 5-15 business days. Expedited review (with clinical justification) takes 24-72 hours.

Q: What if Kymriah isn't on my plan's formulary? A: Request a formulary exception with your oncologist's support, documenting medical necessity and lack of appropriate alternatives.

Q: Can I get an expedited appeal if denied? A: Yes, both internal appeals and external review through IHCAP offer expedited options when delay would jeopardize health.

Q: Does step therapy apply to Kymriah? A: Horizon's policy requires documentation of prior therapy failures, but specific step therapy protocols vary by indication.

Q: What happens if I'm treated out-of-network? A: Contact Horizon to request a single-case agreement for coverage at the certified treatment center, especially if no in-network option exists.

Q: Can my doctor appeal on my behalf? A: Yes, providers can file appeals with written patient consent, and this often improves success rates.

Q: What if I need Kymriah urgently? A: Request expedited prior authorization and, if denied, file expedited internal and external appeals simultaneously.

Q: How do I know if my treatment center is certified? A: Verify through the Kymriah treatment center locator or contact the center directly for REMS certification status.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice, legal advice, or a guarantee of coverage. Always consult with your healthcare provider and insurance plan for specific guidance regarding your situation. Coverage policies and procedures may change; verify current requirements with your insurer.

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