By Counterforce Health Team in Bavencio (avelumab) —

The Requirements Checklist to Get Bavencio (Avelumab) Covered by Aetna (CVS Health) in Texas

Answer Box: Getting Started

Aetna (CVS Health) requires prior authorization for Bavencio (avelumab) across all FDA-approved indications in Texas. The fastest path to approval: 1) Verify active coverage and download the official Bavencio Precertification Request Form, 2) Gather complete pathology reports, imaging, and platinum chemotherapy history (for urothelial carcinoma), 3) Submit via provider portal or fax to 888-267-3277 at least 14 days before planned infusion. Standard decisions take 5-15 business days; expedited reviews (urgent cases) are decided within 24-72 hours. If denied, you have 180 days to appeal internally, then access Texas's Independent Review Organization (IRO) process for binding external review.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria
  4. Coding Hygiene
  5. Documentation Packet
  6. Submission Mechanics
  7. Specialty Pharmacy Routing
  8. After Submission
  9. Denial-Prevention Tips
  10. Appeals Process in Texas
  11. Printable Checklist
  12. FAQ

Who Should Use This Guide

This checklist is designed for patients, caregivers, and healthcare providers navigating Bavencio (avelumab) coverage through Aetna (CVS Health) plans in Texas. You'll find this most helpful if you're dealing with:

  • Metastatic Merkel cell carcinoma requiring single-agent immunotherapy
  • Locally advanced or metastatic urothelial carcinoma needing maintenance therapy after platinum chemotherapy
  • Advanced renal cell carcinoma as first-line treatment with axitinib

Expected outcome: With complete documentation and proper submission, most patients receive approval within 2-3 weeks. Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals by identifying denial reasons and drafting point-by-point rebuttals aligned to each plan's specific requirements.

Member & Plan Basics

Coverage Verification

Before starting the prior authorization process, confirm these essentials:

Requirement What to Check Where to Find It
Active Coverage Policy effective dates, premium status Member ID card, Aetna member portal
Plan Type Commercial, Medicare Advantage, Medicaid Benefits summary, HR department
Specialty Drug Benefits Coverage tier, copay amounts Formulary document, member services
Deductible Status Amount met vs. remaining EOB statements, member portal
Note: Bavencio appears on Aetna's 2024 and 2025 Precertification Lists, requiring prior authorization regardless of plan type.

2026 Formulary Changes

Starting January 1, 2026, Bavencio shifts to non-preferred status for Merkel cell carcinoma, with Zynyz becoming the preferred option. This may trigger step therapy requirements unless contraindicated or previously failed.

Clinical Criteria

FDA-Approved Indications Covered by Aetna

Merkel Cell Carcinoma (MCC)

  • Locally advanced, recurrent, or metastatic disease
  • Adults and pediatric patients ≥12 years
  • ECOG performance status 0-2
  • No prior systemic therapy required

Urothelial Carcinoma (UC)

  • Maintenance after first-line platinum-containing chemotherapy
  • Locally advanced or metastatic disease
  • Stable disease or response documented
  • Treatment initiation 4-10 weeks post-platinum
  • No prior progression on PD-1/PD-L1 inhibitors

Renal Cell Carcinoma (RCC)

  • Advanced, relapsed, or stage IV clear cell histology
  • First-line therapy in combination with axitinib

Exclusion Criteria

Aetna will deny coverage if you have:

  • Disease progression on prior PD-1/PD-L1 inhibitors (nivolumab, pembrolizumab, atezolizumab, durvalumab, or avelumab)
  • Use outside FDA-approved indications without compelling off-label evidence

Coding Hygiene

Required Codes for Billing

Code Type Code Description
HCPCS J9023 Injection, avelumab, 10 mg
ICD-10 (MCC) C4A.0–C4A.9 Merkel cell carcinoma by site
ICD-10 (UC) Site-specific codes Urothelial carcinoma codes
ICD-10 (RCC) C64.9 Malignant neoplasm of kidney

Administration Codes

  • 96413 – IV infusion, up to 1 hour
  • 96415 – Each additional hour
  • 96416 – Prolonged infusion initiation

Standard dosing: 800 mg IV every 2 weeks until progression or unacceptable toxicity.

Documentation Packet

Core Requirements for All Indications

  • Complete pathology report with staging
  • Recent imaging demonstrating disease status
  • ECOG performance status documentation
  • Laboratory results (CBC, comprehensive metabolic panel, liver function tests)
  • Medical necessity letter from oncologist

Indication-Specific Documentation

For Urothelial Carcinoma (Critical)

  • Detailed platinum chemotherapy history (agent, dates, number of cycles)
  • Post-chemotherapy response imaging
  • Documentation of stable disease or response
  • Confirmation of 4-10 week treatment window post-platinum

For Renal Cell Carcinoma

  • Clear cell histology confirmation
  • First-line therapy documentation
  • Concurrent axitinib prescription

Medical Necessity Letter Components

Your oncologist's letter should address:

  1. Clinical problem: Specific diagnosis with staging
  2. Prior treatments: Previous therapies tried, outcomes, and reasons for discontinuation
  3. Clinical rationale: Why Bavencio is appropriate for this patient
  4. Guideline support: FDA labeling and NCCN guideline citations
  5. Dosing plan: Standard 800 mg IV every 2 weeks protocol
  6. Monitoring plan: Response assessment and safety monitoring

Submission Mechanics

Official Forms and Submission Methods

Use the Aetna Bavencio Precertification Request Form available from Aetna's healthcare professional forms page.

Submission Options:

  • Provider portal (preferred method)
  • Fax: 888-267-3277
  • Phone: 866-752-7021 (for questions and confirmation)

Required Fields That Commonly Cause Rejections

  • Patient demographics with correct member ID
  • Prescriber NPI number
  • Complete ICD-10 diagnosis codes
  • Specific dosing regimen (800 mg IV q2 weeks)
  • Site of care justification
  • Prior authorization request reason
Tip: Submit at least 14 days before the planned first infusion to allow for processing time and potential appeals.

Specialty Pharmacy Routing

CVS Specialty Enrollment Process

Since Aetna partners with CVS Specialty for most oncology medications, coordinate enrollment simultaneously with prior authorization:

  1. Complete enrollment form via CVS Specialty Oncology
  2. Submission methods:
    • Fax: 1-800-323-2445
    • Email: [provider contact through CVS Specialty portal]
    • Phone: 1-800-237-2767
  3. Required documentation:
    • Insurance authorization approval
    • Infusion site delivery coordination
    • Patient support services setup

Transfer from Another Specialty Pharmacy

If transferring active therapy:

  • Request prescription transfer authorization from current pharmacy
  • Provide current treatment response documentation
  • Coordinate timing to avoid treatment delays
  • Update insurance information with new pharmacy designation

After Submission

Timeline Expectations

Review Type Timeline When to Use
Standard 5-15 business days Routine requests
Expedited 24-72 hours Urgent medical need
Deemed Approved If no response within timeline Automatic approval

Tracking Your Request

  1. Get confirmation number at submission
  2. Check status via provider portal or member services
  3. Document everything: submission date, confirmation number, contact names
  4. Set calendar reminders for follow-up if no response by expected date

Denial-Prevention Tips

Five Common Pitfalls and How to Avoid Them

  1. Incomplete platinum chemotherapy history (UC patients)
    • Fix: Include detailed records of agent, dates, cycles, and response assessment
  2. Missing performance status documentation
    • Fix: Ensure ECOG 0-2 is clearly documented in clinical notes
  3. Inadequate imaging documentation
    • Fix: Include recent scans showing disease status and staging
  4. Generic medical necessity letters
    • Fix: Customize letter to patient's specific clinical situation and cite FDA labeling
  5. Wrong submission method or incomplete forms
    • Fix: Use current form version and preferred submission portal

Appeals Process in Texas

Internal Appeals (Required First Step)

Timeline: File within 180 calendar days of denial notice Decision timeframe:

  • Standard: 30 days
  • Expedited: 72 hours (single-level plans) or 36 hours (two-level plans)

How to file:

  • Via Availity provider portal
  • Mail to address on denial letter
  • Fax with "Expedited" notation if urgent

Texas Independent Review Organization (IRO)

After exhausting internal appeals, Texas residents can access binding external review:

Eligibility: Denials based on medical necessity, appropriateness, or experimental/investigational determinations Timeline: Request within 4 months of final internal denial Decision timeframe:

  • Standard: 45 days
  • Expedited: 72 hours for life-threatening situations

How to request: Submit IRO form through Texas Department of Insurance website (verify current link) Cost: Approximately $300-500 (fee waivable based on income)

Note: ERISA self-funded employer plans, Medicare, and Medicaid follow federal appeal rules rather than Texas IRO process.

When to Request Expedited Review

Request expedited processing if:

  • Delay would seriously jeopardize life or health
  • Ongoing therapy interruption risks patient harm
  • Physician certifies urgent medical need

Printable Checklist

Before You Start

  • Verify active Aetna coverage and specialty drug benefits
  • Download current Bavencio precertification form
  • Gather insurance card and member ID information
  • Collect complete medical records and imaging

Documentation to Collect

  • Pathology report with staging
  • Recent imaging studies
  • ECOG performance status documentation
  • Laboratory results (CBC, CMP, LFTs)
  • For UC: Complete platinum chemotherapy history
  • Medical necessity letter from oncologist
  • Prior therapy records and outcomes

Submission Requirements

  • Complete all form fields accurately
  • Include prescriber NPI and patient demographics
  • Specify correct ICD-10 and HCPCS codes
  • Submit 14+ days before planned infusion
  • Get confirmation number
  • Set follow-up reminders

After Submission

  • Track status via provider portal
  • Coordinate CVS Specialty enrollment if approved
  • Prepare appeal documents if denied
  • Document all communications and dates

FAQ

How long does Aetna prior authorization take for Bavencio in Texas? Standard reviews take 5-15 business days. Expedited reviews for urgent cases are completed within 24-72 hours.

What if Bavencio is non-formulary on my plan? Submit a formulary exception request with documentation of medical necessity and any contraindications to preferred alternatives.

Can I request an expedited appeal in Texas? Yes, if delay would seriously jeopardize your health. Include physician certification of urgent medical need with your appeal.

Does step therapy apply if I've tried treatments outside Texas? Yes, document all prior therapies regardless of where they were received. Include records of failures, intolerances, or contraindications.

What happens if my internal appeal is denied? Texas residents can request Independent Review Organization (IRO) evaluation within 4 months of the final internal denial for a binding external decision.

Who pays for the IRO review in Texas? The patient typically pays a fee of $300-500, though this may be waived based on income. The insurer pays the IRO's review costs.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and is not medical advice. Coverage decisions depend on individual plan terms and medical circumstances. For specific questions about your coverage, contact Aetna member services directly. For assistance with appeals and prior authorization challenges, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals that align with each payer's specific requirements.

Texas Resources for Help:

  • Texas Department of Insurance Consumer Helpline: 1-800-252-3439
  • Office of Public Insurance Counsel (OPIC): 1-877-611-6742
  • Disability Rights Texas: For Medicaid appeals and advocacy support

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