By Counterforce Health Team in Prolastin-C (alpha1-proteinase inhibitor) —

Do You Qualify for Prolastin-C Coverage by Blue Cross Blue Shield in Georgia? Decision Tree & Next Steps

Answer Box: Getting Prolastin-C Covered in Georgia

Most likely to get approved: Adults with confirmed severe alpha-1 antitrypsin deficiency (Pi*ZZ genotype, AAT level ≤11 µM), emphysema on imaging, non-smoking status, and documented optimal COPD therapy. Blue Cross Blue Shield Georgia typically requires prior authorization through their specialty pharmacy program. First step today: Have your pulmonologist complete the Alpha-1 Proteinase Inhibitor PA form via the Anthem provider portal and gather AAT genotype results, spirometry data, and smoking cessation documentation.

Table of Contents

How to Use This Decision Tree

This guide helps Georgia patients and their clinicians determine eligibility for Prolastin-C (alpha1-proteinase inhibitor) coverage through Blue Cross Blue Shield plans. Work through each section in order to identify your pathway to approval.

Before you start: Gather your insurance card, recent lab results, pulmonary function tests, and any prior therapy documentation. Blue Cross Blue Shield of Georgia (now branded as Anthem Blue Cross and Blue Shield) uses centralized clinical policies for alpha-1 proteinase inhibitors across multiple states.

Note: This decision tree applies to commercial and Medicare Advantage plans. Medicaid coverage follows different pathways through Georgia Department of Community Health.

Eligibility Triage: Do You Qualify?

Step 1: Confirmed Diagnosis

Required elements:

  • Severe hereditary alpha-1 antitrypsin deficiency with AAT serum level ≤11 µM (or equivalent in mg/dL)
  • High-risk genotype (PiZZ, PiZnull, or other severe variants) documented by lab report
  • Clinical emphysema attributable to AAT deficiency

Decision point: ✅ All three present → Continue to Step 2 | ❓ Missing any → Go to "Possibly Eligible" section

Step 2: Clinical Severity

Required evidence:

  • Objective airflow obstruction (FEV₁ reduction on spirometry)
  • CT evidence of emphysema pattern
  • Age ≥18 years

Decision point: ✅ All present → Continue to Step 3 | ❓ Partial → Go to "Possibly Eligible" section

Step 3: Behavioral Requirements

Must document:

  • Non-smoker status (current smoking typically disqualifies)
  • No IgA deficiency with antibodies to IgA (contraindication)
  • On optimal standard COPD therapy

Decision point: ✅ All met → Go to "Likely Eligible" | ❌ Any unmet → Go to "Not Yet" section

If "Likely Eligible": Document Checklist

You meet Blue Cross Blue Shield's core criteria. Focus on gathering complete documentation for a strong prior authorization submission.

Required Clinical Documentation

  • AAT level report with assay type and reference range
  • Genotype/phenotype report (PiZZ, PiZnull, etc.)
  • Pulmonary function tests (FEV₁, FEV₁% predicted, DLCO if available)
  • CT chest imaging documenting emphysema pattern
  • Smoking history and explicit smoking cessation documentation
  • IgA level confirming patient is not IgA-deficient
  • Current COPD medications and pulmonary rehabilitation status

Submission Path

  1. Identify your exact plan: Check your member ID card for specific Blue Cross Blue Shield product (commercial vs Medicare, HMO vs PPO)
  2. Access the PA form: Use the Anthem Georgia drug list portal to locate the Alpha-1 Proteinase Inhibitor medical policy and request form
  3. Prepare dosing details: Standard dosing is 60 mg/kg IV once weekly (maximum 2,800 billable units every 28 days under HCPCS J0224)
  4. Submit via preferred channel: Availity provider portal is typically fastest
Clinician Corner: Include a medical necessity letter referencing the patient's AAT level, genotype, FEV₁ decline rate, and exacerbation history. Cite the FDA labeling for Prolastin-C's approved indication in emphysema due to severe AAT deficiency.

Expected Timeline

  • Standard review: 2-4 weeks from complete submission
  • Expedited review: 3-5 days with strong medical justification for urgency

If "Possibly Eligible": Tests to Request

You may qualify but need additional testing or documentation to confirm eligibility.

Missing Diagnosis Components

If AAT level unknown:

  • Request quantitative serum AAT level (nephelometry or ELISA)
  • If level is borderline, discuss genetic testing with your physician

If genotype unclear:

  • Request SERPINA1 genotyping for S and Z alleles
  • Family history of confirmed AAT deficiency supports testing

If lung disease documentation incomplete:

  • Schedule spirometry if not done within 6 months
  • Consider high-resolution CT chest to document emphysema pattern
  • Pulmonologist consultation may strengthen the case

Timeline to Re-apply

  • Complete testing within 30-60 days
  • Resubmit PA once all required elements are documented
  • Track your progress with a checklist to ensure nothing is missed

If "Not Yet": Alternatives to Discuss

Your current status doesn't meet standard approval criteria, but options may exist.

Address Smoking Status

  • Current smokers: Complete smoking cessation program and document 3-6 months of abstinence
  • Recent quitters: Provide documentation of cessation date and method used
  • Consider nicotine replacement therapy or prescription cessation aids

Optimize COPD Management

  • Ensure maximum bronchodilator therapy (LABA/LAMA combinations)
  • Complete pulmonary rehabilitation if available
  • Update vaccinations (pneumonia, influenza, COVID-19)
  • Document adherence to current therapies

Prepare for Exception Requests

If standard criteria cannot be met, discuss with your physician:

  • Medical necessity for expedited treatment
  • Contraindications to waiting for full optimization
  • Rapid disease progression requiring immediate intervention

If Denied: Appeal Path Chooser

Blue Cross Blue Shield denials can be overturned through Georgia's structured appeal process.

Level 1: Internal Appeal

Timeline: File within 180 days of denial; decision in 30 days (60 days for post-service) How to file: Submit written appeal via member portal or mail to address in denial letter What to include:

  • Copy of denial letter
  • Strengthened medical necessity letter from physician
  • Any additional clinical evidence
  • Request for peer-to-peer review if available

Level 2: Expedited Internal Appeal

When to use: Delay would seriously jeopardize life, health, or ability to regain function Timeline: Decision within 72 hours Special note: In urgent cases, Georgia allows concurrent external review request

Level 3: External Review (Georgia DOI)

Timeline: File within 60 days of final internal denial; decision in 30 business days Cost: Free to consumer How to file: Submit application to Georgia Office of Insurance and Safety Fire Commissioner Binding: Decision is legally binding on the insurer

Tip: Counterforce Health specializes in turning insurance denials into evidence-backed appeals. Their platform analyzes denial letters and plan policies to draft targeted rebuttals with the right clinical facts and citations for medications like Prolastin-C.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
PA Required Prior authorization needed Anthem specialty pharmacy updates Provider News
Medical Benefit Buy-and-bill only, not pharmacy Policy states "must be obtained through buy-and-bill" Clinical Policy
Age Limit ≥18 years Universal criteria in policy Clinical Policy
Dose Limit 2,800 units per 28 days HCPCS J0224 billing limits Clinical Policy
Coverage Period 12 months, then renewal Standard authorization period Clinical Policy

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
"Inadequate genotype documentation" Submit complete SERPINA1 testing results showing Pi*ZZ or equivalent severe variant
"Insufficient lung disease evidence" Provide spirometry showing airflow obstruction and CT demonstrating emphysema pattern
"Patient is current smoker" Document smoking cessation with date and method; provide cotinine testing if needed
"Not medically necessary" Strengthen clinical evidence with exacerbation history, FEV₁ decline rate, and guideline citations
"Step therapy not completed" Note: Prolastin-C is often preferred over Aralast NP/Glassia; verify plan-specific requirements

FAQ: Blue Cross Blue Shield Prolastin-C Coverage

How long does Blue Cross Blue Shield PA take in Georgia? Standard review typically takes 2-4 weeks from complete submission. Expedited review for urgent cases can be completed in 3-5 days.

What if Prolastin-C is non-formulary on my plan? Request a formulary exception through the same PA process. Include documentation of why Prolastin-C is medically necessary over covered alternatives.

Can I request an expedited appeal? Yes, if waiting would seriously jeopardize your health. Georgia allows expedited internal appeals (72 hours) and even concurrent external review for urgent situations.

Does step therapy apply if I've failed treatments outside Georgia? Yes, documented treatment failures from other states are typically accepted. Provide complete medication history with dates, doses, and outcomes.

What's the difference between internal and external review? Internal review is conducted by your insurance company. External review is performed by independent physicians through the Georgia Department of Insurance and is binding on the insurer.

How much does Prolastin-C cost without insurance? Annual costs commonly exceed $80,000 per patient. Payer spending among users has averaged around $127,000 per year in recent analyses, making prior authorization critical for affordability.

For complex cases or persistent denials, consider working with Counterforce Health, which helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Their platform specializes in identifying denial reasons and drafting point-by-point rebuttals aligned to each plan's specific policies.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and coverage criteria can change. Always verify current requirements with your specific Blue Cross Blue Shield plan and consult your healthcare provider for medical decisions.

Sources & Further Reading

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