By Counterforce Health Team in Retevmo (selpercatinib) —

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

Quick Answer: Getting Retevmo Covered by BCBS North Carolina

Blue Cross Blue Shield of North Carolina requires prior authorization for Retevmo (selpercatinib) for RET fusion-positive NSCLC and thyroid cancers. You'll need FDA-approved RET testing results, pathology reports, and clinical documentation. If denied, file internal appeals within 180 days, then external review through Smart NC within 120 days. Success rates for specialty drug appeals are 40-60% with proper documentation.

Your first step today: Contact your oncologist to confirm RET testing was done with an FDA-approved method (like FoundationOne CDx) and gather all treatment records for the prior authorization submission.

Table of Contents

  1. Is Retevmo Covered by BCBS North Carolina?
  2. Prior Authorization Process
  3. Required Documentation
  4. Timeline and Status Checks
  5. Common Denial Reasons
  6. Appeals Process
  7. North Carolina External Review
  8. Costs and Financial Assistance
  9. Frequently Asked Questions
  10. When to Escalate

Is Retevmo Covered by BCBS North Carolina?

Yes, Blue Cross Blue Shield of North Carolina covers Retevmo (selpercatinib), but it requires prior authorization and is typically placed on Tier 5 (specialty tier) of their formulary. Coverage applies to FDA-approved indications:

  • RET fusion-positive non-small cell lung cancer (NSCLC)
  • RET-mutant medullary thyroid cancer
  • RET fusion-positive thyroid cancer (adults and children ≥2 years)

Coverage Requirements at a Glance:

Requirement Details Source
Prior Authorization Required for all indications BCBSNC PA Requirements
Formulary Tier Tier 3 (120mg), Tier 5 (80mg, 160mg) BCBSNC Formulary Updates
RET Testing FDA-approved companion diagnostic only FDA Retevmo Label
Specialty Pharmacy Required BCBSNC Policy
Appeals Deadline 180 days from denial BCBSNC Appeals Process

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Confirm RET Testing (Patient + Oncologist)
    • Verify testing used FDA-approved method (FoundationOne CDx, Oncomine Dx, TruSight Oncology)
    • Non-FDA tests are automatically denied
  2. Gather Clinical Records (Oncology Team)
    • Pathology report with cancer type and stage
    • Complete treatment history
    • Baseline ECG showing QTc <500ms
    • ICD-10 codes matching FDA indications
  3. Submit Prior Authorization (Provider)
    • Use BCBSNC provider portal or fax
    • Include medical necessity letter citing FDA approval and NCCN guidelines
    • Timeline: 3-5 business days for standard review
  4. Track Status (Patient/Provider)
    • Check portal daily after day 3
    • Call provider services at (833) 540-2106 if delayed
Clinician Corner: Your medical necessity letter should emphasize FDA approval for first-line use in RET+ NSCLC (based on LIBRETTO-431 trial) and reference current NCCN guidelines. Include specific RET alteration details and rationale for Retevmo over alternatives.

Required Documentation

Essential Documents for BCBS North Carolina:

  • RET Testing Report: Must be from FDA-approved companion diagnostic
  • Pathology Report: Confirming cancer type, stage, and histology
  • Treatment History: Prior therapies, responses, and reasons for discontinuation
  • Baseline ECG: QTc interval <500ms documented
  • ICD-10 Codes: Matching FDA-approved indications
  • Medical Necessity Letter: From treating oncologist with guideline references

Common Missing Documentation (Top Denial Reasons):

  • RET testing from non-FDA-approved laboratory
  • Missing baseline cardiac monitoring
  • Incomplete prior treatment documentation
  • Wrong ICD-10 codes for indication

Timeline and Status Checks

Standard Timeline:

  • Submission to Decision: 3-5 business days
  • Expedited Review: 72 hours (if urgent)
  • Appeal Response: 30 days (standard), 72 hours (urgent)

How to Check Status:

  • BCBSNC provider portal (providers)
  • Member services: Check your ID card for number
  • Provider services: (833) 540-2106

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
RET testing not FDA-approved Resubmit with FoundationOne CDx or equivalent FDA-approved test report
Missing cardiac monitoring Submit baseline ECG ECG showing QTc <500ms
Incomplete treatment history Provide detailed prior therapy records Treatment notes, response data
Wrong diagnosis code Correct ICD-10 for FDA indication Updated coding
"Not medically necessary" File appeal with guidelines NCCN references, peer review

Appeals Process

Internal Appeals with BCBS North Carolina

Timeline: Must file within 180 days of denial letter

How to File:

  • Online: BCBSNC member portal
  • Phone: Member services number on ID card
  • Mail: Use Member Appeals Form from BCBSNC website

Required Documents:

  • Original denial letter
  • Additional clinical evidence
  • Updated medical necessity letter
  • Member Appeals Form

Response Time:

  • Standard: 30 calendar days
  • Urgent: 72 hours
From our advocates: We've seen BCBS North Carolina approve Retevmo appeals when providers include specific LIBRETTO trial data and emphasize the drug's FDA approval for first-line use. Strong medical necessity letters citing current guidelines significantly improve success rates.

North Carolina External Review

If your internal appeal is denied, North Carolina offers robust external review protections through Smart NC.

Smart NC External Review Process:

Eligibility:

  • State-regulated BCBS plan (not self-funded employer plans)
  • All internal appeals exhausted (or qualify for expedited)
  • Denial based on medical necessity or experimental treatment

Timeline:

  • File within: 120 days of final internal denial
  • Decision time: 45 days (standard), 72 hours (expedited)
  • Urgent cases: 24-72 hours for non-formulary drug denials

How to File:

  • Phone: 1-855-408-1212 (Smart NC helpline)
  • Online: smartnc.org
  • Forms: External Review Request Form from NC Department of Insurance

Success Rates:

  • External review overturns approximately 50% of specialty drug denials
  • Well-documented cases: 40-60% success rate

Smart NC Advantages:

  • Free advocacy support from insurance experts
  • Help completing forms and gathering records
  • Fast expedited review for urgent cases
  • Binding decisions on insurers

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Our platform ingests denial letters and clinical notes to draft point-by-point rebuttals aligned to payer rules, pulling the right citations and clinical facts for maximum success rates.

Costs and Financial Assistance

Typical Costs:

  • Cash Price: $23,000-$26,000 per month
  • Tier 5 Coinsurance: Typically 50% after deductible
  • Potential Monthly Cost: $11,500-$13,000 before assistance

Financial Assistance Options:

Manufacturer Programs:

  • Lilly Cares Foundation: Income-based free drug program
  • Retevmo Savings Program: Copay assistance for commercially insured patients

Independent Assistance:

  • Patient Advocate Foundation: Copay relief programs
  • CancerCare: Financial counseling and assistance
  • North Carolina State Programs: Verify current offerings through NC DHHS

Frequently Asked Questions

How long does BCBS North Carolina prior authorization take? Standard PA decisions are made within 3-5 business days. Expedited reviews for urgent cases are completed within 72 hours.

What if Retevmo is non-formulary on my plan? File a formulary exception request with your medical necessity letter. Emphasize FDA approval and lack of suitable alternatives.

Can I request an expedited appeal? Yes, if delay would seriously jeopardize your health. BCBS NC must respond within 72 hours for urgent appeals.

Does step therapy apply to Retevmo? BCBS NC may require prior chemotherapy for NSCLC or cabozantinib/vandetanib for thyroid cancer. Request exceptions based on contraindications or FDA first-line approval.

What if I need Retevmo while traveling outside North Carolina? Contact member services before traveling. Some plans have national networks; others may require prior approval for out-of-state specialty pharmacy fills.

How do I find a BCBS-approved specialty pharmacy? Call member services or check your plan documents. Common networks include CVS Specialty and Accredo.

When to Escalate

Contact North Carolina Department of Insurance if:

  • BCBS NC violates appeal timelines
  • You're denied external review eligibility
  • You suspect bad faith claim handling

NC Department of Insurance:

  • Phone: 1-855-408-1212 (Smart NC)
  • Website: ncdoi.gov
  • Complaint Form: Available online

Federal Options:

  • CMS: For Medicare Advantage plans
  • Department of Labor: For ERISA plans

Checklist: What to Gather Before You Start

  • Insurance card with member ID
  • FDA-approved RET testing report
  • Complete pathology report
  • Treatment history and response data
  • Baseline ECG results
  • Current oncologist contact information
  • Previous denial letters (if applicable)
  • List of current medications

Working with experienced advocates like Counterforce Health can streamline this process by ensuring all documentation meets payer-specific requirements and appeals are strategically crafted for maximum success.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and state regulations may change. Always verify current requirements with your insurer and consult your healthcare provider for medical decisions. For personalized assistance with North Carolina insurance appeals, contact Smart NC at 1-855-408-1212.

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