By Counterforce Health Team in Bavencio (avelumab) —

How to Renew Bavencio (Avelumab) Coverage with Aetna CVS Health in California: 2025 Requirements & Timeline

Quick Answer: Renewing Your Bavencio Coverage

To renew Bavencio (avelumab) with Aetna CVS Health in California, submit your continuation request at least 14 days before your next infusion using form GR-69328. You'll need recent imaging showing no disease progression, oncology notes confirming tolerability, and documentation of continuous months on therapy. Fax to 1-888-267-3277 or submit via Availity portal. If denied, California residents can request Independent Medical Review (IMR) with roughly 50-60% success rates for well-documented oncology cases.

Table of Contents

  1. When to Start Your Renewal Process
  2. Required Documentation for Continuation
  3. Aetna's 2025 Bavencio Renewal Form
  4. Submission Timeline & Decision Windows
  5. If Your Coverage Lapses
  6. 2026 Formulary Changes to Prepare For
  7. California Appeals Process (IMR)
  8. Personal Renewal Tracker
  9. FAQ

When to Start Your Renewal Process

Renewal Triggers

Aetna CVS Health typically requires prior authorization renewal every 6-12 months for Bavencio, depending on your specific plan. Watch for these signals to start early:

  • Authorization expiration notice in your member portal or EOB
  • Plan year change (January 1st requires re-verification)
  • Formulary updates (Aetna publishes changes in July and January)
  • Six-month treatment milestone (many policies trigger review at this point)
Tip: Set a calendar reminder 30 days before your current authorization expires. This gives you buffer time if additional documentation is needed.

Early Warning Signs

Start your renewal process immediately if you notice:

  • Claims being processed as "pending authorization"
  • Infusion center requesting updated PA information
  • Changes to your cost-share without explanation
  • New step therapy requirements appearing in your plan materials

Required Documentation for Continuation

Core Clinical Requirements

For all Bavencio renewal requests, Aetna requires documentation addressing these key areas per their 2024 precertification form:

Requirement What to Document Source Needed
Disease Status No radiographic or clinical progression Recent imaging report (CT/PET)
Treatment Response No unacceptable toxicity on current regimen Oncology progress notes
Treatment Duration Continuous months of therapy received Treatment log/infusion records
Diagnosis Confirmation ICD-10 codes and disease stage Pathology and staging reports

Indication-Specific Documentation

For Metastatic Merkel Cell Carcinoma:

  • Confirmation of metastatic or locally advanced disease
  • Documentation that patient remains a candidate for systemic therapy
  • Performance status assessment (typically ECOG 0-2)

For Urothelial Carcinoma Maintenance:

  • Evidence of non-progression after first-line platinum chemotherapy
  • Confirmation patient remains in maintenance setting
  • Documentation of original platinum regimen and response

Site-of-Care Documentation

If receiving Bavencio at an outpatient hospital (vs. infusion center), document:

  • Severe venous access issues requiring hospital-level intervention
  • Significant behavioral, physical, or cognitive impairment affecting safety
  • Medical instability requiring cardiopulmonary monitoring

Aetna's 2025 Bavencio Renewal Form

Form Details

Use "Bavencio (avelumab) Injectable Medication Precertification Request" form GR-69328 (4-24) for all continuation requests. This is the same form used for initial approvals, but check the "Continuation of therapy" section.

Submission Methods:

  • Fax: 1-888-267-3277 (preferred for urgent requests)
  • Phone: 1-866-752-7021 (commercial medical precertification)
  • Online: Via Availity portal or Novologix for specialty drugs

Critical Form Sections for Renewal

Section G - Continuation Requests:

  • Date of last treatment
  • Number of continuous months on Bavencio
  • Whether patient experienced disease progression or unacceptable toxicity
  • Indication for continued therapy

Clinical Information to Include:

  • Primary and secondary ICD-10 diagnosis codes
  • Line of therapy (first-line maintenance vs. subsequent)
  • Prior platinum-based chemotherapy details
  • Previous PD-1/PD-L1 exposure history

Submission Timeline & Decision Windows

Provider Submission Requirements

Submit at least 14 days before next scheduled infusion per Aetna's precertification guidelines. This prevents treatment delays and ensures continuous coverage.

Aetna Decision Timeframes

For California exchange plans, Aetna must decide within specific windows per their 2024 plan documents:

  • Non-urgent requests: 72 hours (deemed approved if no decision)
  • Urgent/expedited: 24 hours (deemed approved if no decision)
Note: These "deemed approval" rules apply when Aetna confirms receipt but fails to issue a determination within the specified timeframe.

Practical Timeline

Day Action Responsibility
-30 Check authorization expiration date Patient/clinic
-21 Gather renewal documentation Clinic
-14 Submit renewal request Clinic
-10 Follow up if no acknowledgment Clinic
-3 Contact Aetna if no decision Patient/clinic
0 Scheduled infusion date Patient

If Your Coverage Lapses

Immediate Steps

  1. Contact your oncology team to request urgent reauthorization
  2. Call Aetna member services to understand the specific denial reason
  3. Request expedited review if treatment delay poses health risks
  4. Explore bridge therapy options through your clinic's financial counselor

Bridge Therapy Options

While not guaranteed, some options may be available during appeal periods:

  • Manufacturer patient assistance: EMD Serono/Pfizer may provide temporary supply during appeals
  • Clinic compassionate use: Some cancer centers maintain emergency drug supplies
  • Insurer bridge programs: Aetna may authorize short-term coverage during good-faith appeals
Important: Bridge therapy availability varies and should never be assumed. Always pursue urgent appeal processes simultaneously.

Emergency Authorization

For life-threatening situations, California law requires insurers to provide emergency coverage. Document with your oncologist that treatment delay would:

  • Jeopardize life or major bodily function
  • Cause irreversible disease progression
  • Result in loss of performance status that precludes future treatment

2026 Formulary Changes to Prepare For

Upcoming Status Changes

According to Aetna's January 2026 medical drug list changes:

Merkel Cell Carcinoma:

  • Bavencio moves from preferred to non-preferred
  • Zynyz (retifanlimab) becomes the preferred PD-L1 agent

Renal Cell Carcinoma:

  • Bavencio added as non-preferred
  • Keytruda and Opdivo products become preferred

Impact on Current Patients

If you're stable on Bavencio before 2026:

  • Transition policies may allow continued coverage through the plan year
  • Medical exceptions can be requested if switching isn't clinically appropriate
  • Cost-sharing may increase for non-preferred status

Planning Ahead

Discuss with your oncologist:

  • Whether preferred alternatives are clinically appropriate
  • Documentation needed for medical exception requests
  • Potential timing for any medically necessary switches

California Appeals Process (IMR)

When to Request IMR

After Aetna's internal appeal process, California residents can request Independent Medical Review (IMR) through the Department of Managed Health Care (DMHC) if coverage is denied as:

  • Not medically necessary
  • Experimental or investigational
  • Not a covered benefit

Success Rates for Oncology

California IMR data shows approximately 50-61% success rates for specialty drugs with strong clinical evidence, according to DMHC analyses. Bavencio's FDA approval and NCCN guideline support typically qualify as "strong evidence."

IMR Timeline

  • Standard IMR: 45 days from complete application
  • Expedited IMR: 72 hours to 7 days for urgent cases
  • No cost to the patient
  • Binding decision on the insurer

Maximizing IMR Success

Include in your IMR application:

  • Detailed medical necessity letter from oncologist
  • FDA labeling showing approved indication
  • NCCN or other guideline references
  • Imaging and lab results supporting ongoing benefit
  • Documentation of prior treatment failures or contraindications to alternatives

DMHC Help Center: 888-466-2219 for assistance with IMR applications.

Personal Renewal Tracker

Key Information to Track

Create a simple log with these fields:

  • Current authorization expiration date
  • Last imaging date and results
  • Months on Bavencio therapy
  • Recent lab values (CBC, CMP, TSH)
  • Performance status at last visit
  • Any toxicity or dose modifications

Important Contacts

Keep this information readily available:

  • Oncologist's office phone and fax
  • Aetna member services: [number from insurance card]
  • Prior authorization fax: 1-888-267-3277
  • DMHC Help Center: 888-466-2219

Document Organization

Maintain copies of:

  • Original Bavencio approval letter
  • Recent imaging reports
  • Oncology visit notes
  • Treatment logs showing infusion dates
  • Any prior appeal correspondence

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to draft evidence-backed rebuttal letters. Their platform helps patients and clinicians navigate complex prior authorization requirements and appeals processes for specialty medications like Bavencio.

FAQ

How long does Aetna CVS Health prior authorization renewal take in California? Standard decisions typically take up to 72 hours for California exchange plans. Submit at least 14 days before your next infusion to ensure continuous coverage.

What if Bavencio becomes non-formulary in 2026? You can request a formulary exception with medical necessity documentation. Aetna may also offer transition policies allowing continued coverage for stable patients.

Can I request expedited review for Bavencio renewal? Yes, if treatment delay would pose serious health risks. Have your oncologist document that delay could jeopardize life or major bodily function.

Does step therapy apply to Bavencio renewals? Starting in 2026, Aetna may require trial of preferred agents (Zynyz for MCC, Keytruda/Opdivo for RCC) unless contraindicated or previously failed.

What counts as "disease progression" for renewal purposes? Radiographic progression per RECIST criteria, new metastatic sites, or clinical deterioration requiring treatment change. Stable disease or response supports continuation.

How do I get help with the renewal process? Contact your oncology team's financial counselor, call Aetna member services, or reach out to Counterforce Health for assistance with complex appeals.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan for personalized guidance. For additional help with insurance appeals in California, contact the Department of Managed Health Care at 888-466-2219.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.