By Counterforce Health Team in Kymriah (tisagenlecleucel) —

How to Get Kymriah (tisagenlecleucel) Covered by Blue Cross Blue Shield of Texas: Complete Prior Authorization and Appeal Guide

Answer Box: Getting Kymriah Covered by BCBS Texas

Kymriah (tisagenlecleucel) requires prior authorization through Blue Cross Blue Shield of Texas using specific forms (#844 for DLBCL, #846 for follicular lymphoma). Treatment must occur at a BCBS-designated Blue Distinction Center for Cellular Immunotherapy. The fastest path: 1) Verify your plan covers CAR-T therapy at certified centers, 2) Submit PA request through the Medical and Pharmacy Benefit Drug Prior Auth portal at availity.com, 3) Include CD19-positive diagnosis confirmation and prior therapy documentation. If denied, you have 60 days to appeal internally, then 120 days for external review through Texas's Independent Review Organization system.

Table of Contents

  1. Before You Start: Coverage Verification
  2. What You Need to Gather
  3. Step-by-Step Prior Authorization Process
  4. Medical Necessity Requirements
  5. Common Denial Reasons & Solutions
  6. Appeals Process in Texas
  7. Financial Assistance Options
  8. Frequently Asked Questions
  9. Quick Reference Checklist

Before You Start: Coverage Verification

Confirm Your Plan Type

Blue Cross Blue Shield of Texas operates as part of the larger BCBS Association network, but your specific coverage depends on whether you have:

  • Commercial/employer-sponsored plan: Standard BCBS Texas coverage
  • Medicare Advantage: Different formulary and appeal processes
  • Medicaid managed care: State-specific requirements apply
Note: Self-funded employer plans (ERISA) follow federal appeal rules rather than Texas state processes.

Verify Treatment Center Requirements

Kymriah must be administered at a BCBS Blue Distinction Center for Cellular Immunotherapy. Contact your treatment center to confirm they're BCBS-certified before starting the authorization process.

Check Medical vs. Pharmacy Benefit

Kymriah typically falls under your medical benefit rather than pharmacy coverage because it's administered by healthcare providers in clinical settings. This affects your copay structure and prior authorization pathway.

What You Need to Gather

Clinical Documentation Required

  • Diagnosis confirmation: Pathology report showing CD19-positive B-cell malignancy
  • ICD-10 codes: Specific diagnostic codes for your condition
  • Prior therapy records: Documentation of previous treatments and outcomes
  • Lab results: Recent blood work showing organ function
  • Imaging studies: CT, PET scans showing disease status
  • Treatment history: Failed or contraindicated therapies

Insurance Information

  • Current BCBS Texas member ID card
  • Policy details and benefit summary
  • Previous authorization numbers (if applicable)
  • Prior denial letters or EOBs

Step-by-Step Prior Authorization Process

Step 1: Access the Correct Forms

BCBS Texas requires specific prior authorization forms based on your diagnosis:

  • Form #844: For diffuse large B-cell lymphoma
  • Form #846: For follicular lymphoma
  • Form for ALL: Contact BCBS directly for pediatric/young adult acute lymphoblastic leukemia

Step 2: Submit Through Official Portal

Submit your prior authorization request through the Medical and Pharmacy Benefit Drug Prior Auth portal via the provider portal. If online submission isn't possible, call the prior authorization number on your member ID card.

Step 3: Include Complete Documentation

Your submission packet should contain:

  1. Completed PA form with all required fields
  2. Clinical notes supporting medical necessity
  3. Lab results and imaging studies
  4. Prior therapy documentation
  5. Treatment plan from certified center

Step 4: Track Your Submission

  • Standard timeline: 30 days for non-urgent requests
  • Expedited timeline: 72 hours for urgent cases
  • Keep your reference number for follow-up calls
Tip: Request expedited review if treatment delays could worsen your condition.

Medical Necessity Requirements

Clinical Criteria for Coverage

For B-cell Acute Lymphoblastic Leukemia:

  • CD19-positive diagnosis confirmed by pathology
  • Age ≤25 years at time of infusion
  • Relapsed or refractory disease after standard therapy
  • Adequate organ function for treatment

For Diffuse Large B-Cell Lymphoma:

  • Histologically confirmed DLBCL
  • Relapsed or refractory after ≥2 lines of systemic therapy
  • No prior engineered T-cell therapy
  • Treatment at certified center

For Follicular Lymphoma:

  • Histologically confirmed diagnosis
  • Relapsed or refractory after ≥2 lines of systemic therapy
  • Age ≥18 years at infusion
  • Meets performance status requirements

Clinician Corner: Medical Necessity Letter

Your oncologist's letter should include:

  • Patient history: Diagnosis date, staging, molecular markers
  • Prior treatments: Specific regimens tried, dates, outcomes, toxicities
  • Clinical rationale: Why Kymriah is appropriate now
  • Guideline support: NCCN, FDA labeling, or other evidence
  • Treatment plan: Conditioning regimen, monitoring protocol

Common Denial Reasons & Solutions

Denial Reason How to Address Documentation Needed
Missing CD19 positivity Submit flow cytometry results Pathology report with CD19 expression
Not at certified center Confirm center designation BCBS Blue Distinction verification
Insufficient prior therapy Document treatment history Pharmacy records, infusion logs
Inadequate organ function Submit recent labs Complete metabolic panel, cardiac function
Missing conditioning plan Provide treatment protocol Detailed pre-treatment regimen

Appeals Process in Texas

Internal Appeal (First Level)

  • Timeline to file: 60 days from denial notice
  • BCBS decision time: 30 days (72 hours if expedited)
  • How to submit:
    • Phone: 1-888-657-6061
    • Fax: 1-855-212-8110
    • Mail: Blue Cross and Blue Shield of Texas, Attn: Complaints and Appeals Department, P.O. Box 660717, Dallas, TX 75266-0717

External Review (Independent Review Organization)

If your internal appeal is denied, Texas law provides access to an Independent Review Organization (IRO):

  • Timeline to file: 120 days from internal appeal decision
  • Cost: Free to you (insurer pays)
  • Decision timeline: 20 days (5 days if expedited)
  • Binding: IRO decision is final and binding on BCBS

Texas Department of Insurance Resources

For additional help with appeals:

  • Consumer helpline: 1-800-252-3439
  • Office of Public Insurance Counsel: 1-877-611-6742
  • IRO information line: 1-866-554-4926

Financial Assistance Options

KYMRIAH CARES Program

Novartis offers comprehensive patient support through KYMRIAH CARES:

  • Co-pay assistance for eligible patients
  • Case management throughout treatment
  • Insurance benefit verification
  • Travel assistance for qualifying patients
  • Contact: 1-844-459-6742 (1-844-4KYMRIAH)

Additional Support Programs

  • Novartis Universal Co-pay Program: $25/month copay (up to $15,000 annual benefit)
  • Foundation grants: Patient Advocate Foundation, Leukemia & Lymphoma Society
  • Hospital financial assistance: Many treatment centers offer charity care programs

When navigating complex prior authorizations and appeals for expensive specialty medications like Kymriah, Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with each payer's specific requirements, potentially saving months in the approval process.

Frequently Asked Questions

How long does BCBS Texas prior authorization take for Kymriah? Standard requests receive decisions within 30 days. Expedited requests are decided within 72 hours if you meet urgency criteria.

What if Kymriah isn't on my formulary? As a CAR-T therapy, Kymriah typically requires prior authorization regardless of formulary status. Work with your oncologist to submit a medical necessity request.

Can I get treatment while my appeal is pending? You must request continued services within 10 days of your denial notice to maintain coverage during the appeal process.

Does step therapy apply to CAR-T therapies? BCBS Texas requires documentation of prior therapies, but this isn't traditional step therapy since Kymriah is typically used after multiple treatment failures.

What happens if the external review denies coverage? IRO decisions are binding, but you may have options through state insurance regulators if you believe the review process was flawed.

How do I find a BCBS-certified treatment center? Use the BCBS provider finder to locate Blue Distinction Centers for Cellular Immunotherapy in Texas.

Quick Reference Checklist

Before Submitting PA:

  • Confirm treatment center is BCBS-certified
  • Gather pathology report showing CD19 positivity
  • Document all prior therapies and outcomes
  • Obtain recent lab results and imaging
  • Complete appropriate PA form (#844 or #846)

During Review:

  • Track submission with reference number
  • Follow up if no response within timeline
  • Prepare for potential peer-to-peer review
  • Document all communications

If Denied:

  • File internal appeal within 60 days
  • Include additional clinical evidence
  • Request expedited review if urgent
  • Prepare for external review if needed

For patients facing complex insurance hurdles, specialized support services like Counterforce Health can streamline the appeal process by creating targeted rebuttals based on your specific payer's policies and requirements.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage policies vary by specific plan. Always consult with your healthcare provider and insurance company for personalized guidance. For additional help with Texas insurance appeals, contact the Texas Department of Insurance at 1-800-252-3439.

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