By Counterforce Health Team in Gattex (teduglutide) —

Do You Qualify for Gattex (Teduglutide) Coverage by Blue Cross Blue Shield in Florida? Decision Tree & Appeals Guide

Answer Box: Getting Gattex Covered in Florida

Most likely eligible: Diagnosed short bowel syndrome (SBS) with documented parenteral nutrition dependence ≥3 times weekly for 12+ months, age ≥1 year, gastroenterologist involved.

Fastest path: Submit prior authorization via CoverMyMeds portal with complete documentation including PN logs, colonoscopy results, and specialist consultation notes.

First step today: Contact your gastroenterologist to gather required documentation and confirm they'll handle the PA submission. Florida Blue decides within 72 hours for standard requests, 24 hours for urgent cases.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible" - Your Action Plan
  4. If "Possibly Eligible" - Tests to Request
  5. If "Not Yet" - Alternative Strategies
  6. If Denied - Appeals Pathway
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & Fixes
  9. FAQ: Florida Blue & Gattex Coverage

How to Use This Decision Tree

This guide helps patients and clinicians navigate Florida Blue's prior authorization requirements for Gattex (teduglutide). Work through each section systematically:

  • Start with the eligibility triage to understand where you stand
  • Follow the recommended path based on your eligibility status
  • Use the appeals section if you receive a denial
  • Reference the FAQ for specific questions about Florida Blue's process
Note: This is not medical advice. Always work with your healthcare team and verify current policy requirements with Florida Blue directly.

Eligibility Triage: Do You Qualify?

Answer these questions to determine your likelihood of approval:

✅ Likely Eligible If:

  • Confirmed SBS diagnosis with <200 cm functional small bowel (documented via imaging/surgical reports)
  • Parenteral nutrition dependence ≥3 times weekly for 12+ months with detailed PN logs
  • Age ≥1 year (pediatric and adult patients eligible)
  • Gastroenterologist consultation within past 6 months
  • Recent colonoscopy (within 6 months) and lab work (bilirubin, alkaline phosphatase, lipase, amylase)
  • Failed conventional management (optimized enteral nutrition, anti-diarrheal medications)

⚠️ Possibly Eligible If:

  • SBS diagnosis confirmed but PN dependence <12 months documented
  • Missing recent colonoscopy or required lab work
  • No specialist consultation yet arranged
  • Incomplete documentation of prior therapy failures

❌ Not Yet Eligible If:

  • No confirmed SBS diagnosis or >200 cm functional bowel remaining
  • No parenteral nutrition dependence or <3 times weekly
  • Age <1 year
  • No documentation of failed conventional therapies

If "Likely Eligible" - Your Action Plan

Document Checklist

Gather these items before submitting your prior authorization:

Medical Documentation:

  • Surgical reports confirming bowel length/SBS diagnosis
  • Parenteral nutrition orders and administration logs (12+ months)
  • Gastroenterologist consultation notes
  • Colonoscopy report (within 6 months)
  • Lab results: liver enzymes, pancreatic enzymes (within 6 months)

Insurance Information:

  • Florida Blue member ID and policy details
  • Prior authorization form (available via provider portal)
  • Prescription from gastroenterologist

Submission Process

Step 1: Your gastroenterologist submits PA via CoverMyMeds electronic portal (preferred method)

Step 2: Alternative submission by fax using Florida Blue's standard prior authorization forms

Step 3: Florida Blue reviews and responds within 72 hours (standard) or 24 hours (expedited/urgent)

Step 4: If approved, obtain Gattex from designated specialty pharmacy (Accredo, CVS/Caremark)

Tip: Request expedited review if your doctor determines waiting could seriously jeopardize your health - Florida Blue must respond within 24 hours for urgent cases.

If "Possibly Eligible" - Tests to Request

Missing Documentation Strategy

If PN dependence <12 months documented:

  • Request detailed PN administration records from all treatment facilities
  • Ask your care team to document frequency and medical necessity
  • Consider expedited review if health is deteriorating

If missing colonoscopy/labs:

  • Schedule colonoscopy within 6 months of PA submission
  • Order comprehensive metabolic panel including liver and pancreatic enzymes
  • Ensure gastroenterologist reviews all results before PA submission

Timeline to Re-apply:

  • Gather missing documentation within 30-60 days
  • Resubmit complete PA package
  • Consider peer-to-peer review if initially denied due to incomplete information

If "Not Yet" - Alternative Strategies

Preparing for Exception Requests

Build Your Case:

  • Document all attempted therapies and their outcomes
  • Request second opinion from SBS specialist if needed
  • Gather evidence of medical necessity despite not meeting standard criteria

Alternative Treatments to Document:

  • Optimized parenteral nutrition regimens
  • Enteral nutrition maximization attempts
  • Anti-diarrheal medication trials
  • Surgical options considered/attempted

Counterforce Health specializes in helping patients navigate complex prior authorization requirements and can assist in building compelling medical necessity cases for specialty medications like Gattex when standard criteria aren't fully met.

If Denied - Appeals Pathway

Florida Blue Appeals Process

Level 1: Internal Appeal

  • Timeline: File within 180 days of denial notice
  • Decision time: 30 days for future treatments, 60 days for services already provided
  • How to file: Submit written appeal to Florida Blue with additional documentation

Level 2: External Review

  • Timeline: Request within 4 months of final internal denial
  • Decision time: Up to 45 days (standard), 72 hours (expedited)
  • How to file: Contact Florida Department of Financial Services at 1-877-693-5236
  • Cost: Free to consumer

Appeal Scripts & Templates

Patient Phone Script for Florida Blue: "I'm calling to appeal the denial of prior authorization for Gattex (teduglutide) for short bowel syndrome. My member ID is [ID number]. I believe the denial was incorrect because [specific reason]. I'd like to request a peer-to-peer review with my gastroenterologist and understand my appeal rights."

Peer-to-Peer Request Script for Clinicians: "I'm requesting a peer-to-peer review for [patient name] regarding the denial of Gattex (teduglutide). The patient meets all medical necessity criteria with documented SBS and PN dependence. I have additional clinical information that wasn't included in the initial review."

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Timeline
Prior Authorization Required before dispensing Florida Blue PA portal 72 hours decision
Specialist Consultation Gastroenterologist involvement Provider network directory Before PA submission
Colonoscopy Within 6 months of request Imaging/procedure reports Every 6-12 months
PN Documentation 12+ months, ≥3x weekly Hospital/clinic records Ongoing
Age Requirement ≥1 year old Medical records At diagnosis

Common Denial Reasons & Fixes

Denial Reason How to Overturn Required Documents
"No documented SBS" Submit surgical reports, imaging Pathology reports, operative notes
"Insufficient PN dependence" Provide detailed PN logs Administration records, nursing notes
"Missing specialist consultation" Arrange gastroenterology consult Consultation notes, treatment plan
"Incomplete lab work" Submit recent lab results CBC, CMP, liver enzymes within 6 months
"Not medically necessary" Request peer-to-peer review Clinical rationale, guideline citations
From our advocates: We've seen cases where patients were initially denied for "insufficient documentation" but approved after submitting complete PN administration logs spanning the full 12-month requirement period. The key is thorough record-keeping from day one of PN therapy.

Clinician Corner: Medical Necessity Letter

Essential Elements to Include:

Clinical Rationale:

  • Detailed SBS diagnosis with bowel length measurements
  • Parenteral nutrition dependence documentation (frequency, volume, duration)
  • Failed attempts at enteral nutrition optimization
  • Patient's functional status and quality of life impact

Supporting Evidence:

  • FDA labeling for Gattex in SBS patients ≥1 year
  • Clinical trial data showing PN reduction in responders
  • Gastroenterology society guidelines supporting GLP-2 analog use
  • Patient-specific contraindications to alternative therapies

Monitoring Plan:

  • Regular assessment of PN requirements
  • Periodic colonoscopy screening
  • Laboratory monitoring for adverse effects
  • Treatment goals and success metrics

When standard approaches aren't sufficient, Counterforce Health helps clinicians develop evidence-backed appeals that address specific payer criteria and maximize approval chances.

FAQ: Florida Blue & Gattex Coverage

Q: How long does Florida Blue prior authorization take? A: Standard requests receive decisions within 72 hours. Expedited/urgent requests are decided within 24 hours when medical urgency is documented.

Q: What if Gattex is non-formulary on my plan? A: You can request a formulary exception with medical necessity documentation. Your doctor must demonstrate why Gattex is medically necessary compared to formulary alternatives.

Q: Can I request an expedited appeal in Florida? A: Yes, if your doctor determines that waiting could seriously jeopardize your health. Both internal and external reviews can be expedited.

Q: Does step therapy apply to Gattex? A: Florida Blue typically requires documentation of failed conventional therapies (optimized PN, enteral nutrition attempts) before approving Gattex.

Q: What specialty pharmacies does Florida Blue use? A: Gattex must be obtained through participating specialty pharmacies including Accredo and CVS/Caremark.

Q: How much does Gattex cost without insurance? A: Approximately $46,893 per 30-vial kit or $1,798 per single vial (wholesale acquisition cost). Patient assistance programs may be available.

When to Escalate to State Regulators

Contact the Florida Department of Financial Services if:

  • Florida Blue doesn't respond within required timelines
  • You believe the denial violates Florida insurance law
  • You need help navigating the external review process

Contact Information:

  • Phone: 1-877-693-5236 (Insurance Consumer Helpline)
  • Website: Submit complaints online through DFS portal
  • Address: Florida Department of Financial Services, Division of Consumer Services

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and requirements change frequently. Always verify current requirements with Florida Blue directly and work with your healthcare team to determine the most appropriate treatment approach. For personalized assistance with prior authorization and appeals, consult with healthcare coverage specialists or patient advocacy organizations.

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