By Counterforce Health Team in Retevmo (selpercatinib) —

How to Get Retevmo (Selpercatinib) Covered by Blue Cross Blue Shield in New York: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Retevmo Covered by Blue Cross Blue Shield in New York

Retevmo (selpercatinib) requires prior authorization from Blue Cross Blue Shield in New York for RET fusion-positive NSCLC and RET-mutant thyroid cancers. The fastest path to approval: (1) Confirm RET testing with an FDA-approved companion diagnostic, (2) Submit PA request through your Blue Cross provider portal with complete clinical documentation, and (3) If denied, file an internal appeal within 180 days, followed by New York's external review process if needed. New York patients benefit from binding external appeals through the Department of Financial Services, with expedited 24-72 hour decisions for urgent oncology cases.

Start today: Contact your oncologist to request the Blue Cross prior authorization form and gather your RET testing results.

Table of Contents

Before You Start: Verify Your Coverage

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all Blue Cross plans Blue Cross member portal
Formulary Tier Specialty tier (varies by plan) Plan formulary document
RET Testing FDA-approved companion diagnostic required Oncologist or pathology report
Age Requirement ≥18 years for NSCLC, ≥2 years for thyroid cancer FDA prescribing information
Prescriber Oncologist or hematologist required Plan provider directory

First, confirm these basics:

  1. Plan type: Commercial Blue Cross plans in New York follow standard prior authorization processes. Medicaid managed care plans may have different requirements.
  2. In-network status: Verify your oncologist is in-network to avoid additional barriers.
  3. Pharmacy vs. medical benefit: Retevmo is typically covered under the pharmacy benefit as a specialty medication.

What You Need to Gather

Essential Documentation Checklist

Clinical Records:

Prior Authorization Forms:

  • Blue Cross specialty drug PA form (verify current form)
  • Physician attestation of medical necessity
  • Treatment plan with dosing rationale
Tip: Request forms early. Blue Cross PA forms are updated annually, and using outdated versions can delay approval.

Step-by-Step: Fastest Path to Approval

1. Confirm RET Status (Patient/Oncologist)

Timeline: 5-10 business days for testing results

  • Order FDA-approved RET fusion testing if not already completed
  • Ensure test report clearly documents RET alteration type
  • Submit via: Oncologist orders through pathology lab

2. Complete Prior Authorization Request (Oncologist's office)

Timeline: 1-2 business days to prepare

  • Download current Blue Cross PA form from provider portal
  • Include all required clinical documentation
  • Submit via: Blue Cross provider portal or fax (verify current fax number)

3. Submit Clean Request Packet (Clinic staff)

Timeline: Same day submission

  • Medical necessity letter with NCCN guideline references
  • RET testing report
  • Prior therapy documentation showing failures/contraindications
  • Submit via: Electronic submission preferred for faster processing

4. Track Your Request (Patient/clinic)

Timeline: 15 business days for standard review

  • Document submission confirmation number
  • Follow up at 10 business days if no response
  • Contact: Blue Cross member services at number on insurance card

5. Address Any Requests for Additional Information

Timeline: 3-5 business days to respond

  • Respond promptly to avoid automatic denial
  • Provide exactly what's requested, nothing extra
  • Submit via: Same method as original request

Medical Necessity Requirements

NSCLC (RET Fusion-Positive)

Required criteria per NCCN Guidelines:

  • Locally advanced or metastatic NSCLC
  • RET fusion confirmed by FDA-approved test
  • Age ≥18 years
  • No prior RET inhibitor therapy
  • ECOG performance status documented

Dosing requirements:

  • <50 kg: 120 mg twice daily
  • ≥50 kg: 160 mg twice daily

Thyroid Cancer (RET-Mutant/Fusion-Positive)

Required criteria:

  • Advanced or metastatic disease requiring systemic therapy
  • RET mutation (for MTC) or RET fusion (for thyroid cancer) confirmed
  • Age ≥2 years (some plans require ≥12 years)
  • RAI-refractory status for differentiated thyroid cancer (when applicable)

Safety Monitoring Requirements

Baseline assessments:

  • QT interval measurement (ECG)
  • Liver function tests (AST/ALT)
  • Electrolytes (potassium, magnesium, calcium)
  • Blood pressure assessment

Ongoing monitoring:

  • Regular ECGs for QT prolongation
  • Liver function monitoring
  • Blood pressure checks
  • Assessment for interstitial lung disease symptoms
Note: QT prolongation occurs in 7% of patients, requiring careful drug interaction screening and cardiac monitoring.

If You're Asked for More Information

Common Information Requests

"Need more details on prior therapies":

  • Provide specific drug names, dates, duration of treatment
  • Document reason for discontinuation (progression, toxicity, intolerance)
  • Include relevant imaging showing progression

"Clarify RET testing methodology":

  • Confirm FDA-approved companion diagnostic was used
  • Provide full pathology report, not just summary
  • Include laboratory accreditation information

"Medical necessity unclear":

  • Submit NCCN guideline excerpts supporting first-line use
  • Include oncologist letter explaining treatment rationale
  • Provide literature supporting Retevmo's efficacy in your specific RET alteration

If Your Request Is Denied

Understanding Your Denial Letter

Look for specific denial codes:

  • PA-001: Missing prior authorization
  • MED-002: Not medically necessary
  • FORM-003: Incomplete documentation
  • STEP-004: Step therapy required

Immediate Next Steps

  1. Request peer-to-peer review (if available)
  2. File internal appeal within 180 days
  3. Gather additional supporting evidence
  4. Consider expedited appeal if clinically urgent

New York Appeals Process

Internal Appeal (Required First Step)

Timeline: 30 days for standard, 72 hours for expedited How to file: Blue Cross member portal or written request Required: Original denial letter, supporting medical records, physician letter

External Review (After Internal Appeal)

New York's external review process is binding on insurers.

Appeal Type Timeline When to Use
Standard 30 days Non-urgent denials
Expedited 72 hours Serious health risk
Urgent drug 24 hours Immediate treatment needed

Filing requirements:

  • Complete New York External Appeal Application
  • $25 fee (waived for financial hardship, refunded if you win)
  • Submit within 4 months of final internal denial
  • Include supporting medical literature
From our advocates: We've seen many Retevmo denials overturned on external appeal in New York when patients included peer-reviewed studies showing superior outcomes with RET-targeted therapy versus chemotherapy. The key is demonstrating that Retevmo isn't just "another option" but the guideline-preferred treatment for your specific RET alteration.

Need help? Contact Community Health Advocates at 888-614-5400 for free assistance with New York appeals.

Common Denial Reasons & Solutions

Denial Reason How to Overturn
RET testing not FDA-approved Submit new test results from approved companion diagnostic
Step therapy not completed Provide documentation of contraindications to first-line agents
Not medically necessary Include NCCN guidelines showing preferred status
Missing performance status Submit ECOG assessment from oncologist
QT risk not addressed Provide baseline ECG and monitoring plan

Renewal and Re-authorization

When to reapply: 90 days before current authorization expires

Required documentation for renewal:

  • Updated imaging showing response or stable disease
  • Oncologist assessment of continued benefit
  • Documentation of acceptable tolerability
  • Current performance status

Calendar reminder: Set alerts at 120, 90, and 60 days before expiration to ensure continuous coverage.

Cost Savings and Support Programs

Manufacturer Support

  • Lilly Cares Foundation: Free medication for eligible patients
  • Retevmo copay assistance: May reduce out-of-pocket costs for commercially insured patients

Additional Resources

At Counterforce Health, we help patients navigate complex prior authorization and appeals processes by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to create point-by-point rebuttals that align with payer requirements, helping patients get the medications they need faster.

FAQ

How long does Blue Cross PA take in New York? Standard prior authorization decisions are required within 15 business days. Expedited requests for urgent cases must be decided within 72 hours.

What if Retevmo is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and that preferred alternatives are inappropriate or ineffective.

Can I request an expedited appeal? Yes, if delay in treatment poses a serious risk to your health. Your oncologist must certify the urgent medical need.

Does step therapy apply if I failed treatments outside New York? Prior treatment failures from any location should count toward step therapy requirements. Provide complete treatment records from all providers.

What happens if I miss an appeal deadline? You may request an extension for good cause (hospitalization, natural disaster, etc.) or explore other options like state insurance commissioner complaints.

How much does Retevmo cost without insurance? Cash prices range from approximately $23,000-$26,000 per 30-day supply, making insurance coverage essential for most patients.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and should not replace professional medical or legal advice. Coverage policies vary by plan and change frequently. Always verify current requirements with your specific Blue Cross Blue Shield plan and consult your healthcare team for medical decisions. For personalized assistance with complex prior authorization challenges, Counterforce Health specializes in turning insurance denials into successful appeals through evidence-based advocacy.

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