By Counterforce Health Team in Tysabri (natalizumab) —

Do You Qualify for Tysabri (natalizumab) Coverage by Blue Cross Blue Shield in New York? Complete Decision Tree & Appeals Guide

Answer Box: Tysabri Coverage by BCBS in New York

Yes, you likely qualify for Tysabri (natalizumab) coverage by Blue Cross Blue Shield in New York if: you have relapsing multiple sclerosis with documented disease activity, have tried/failed at least one other DMT, and can complete the required TOUCH program enrollment. Fastest path: Your neurologist submits prior authorization with MRI results, JCV antibody status, and TOUCH enrollment confirmation. Start today: Call your doctor to request JCV testing and begin TOUCH enrollment at touchprogram.com.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If "Likely Eligible": Your Next Steps
  4. If "Possibly Eligible": Tests and Timeline
  5. If "Not Yet Eligible": Alternative Options
  6. If Denied: Appeals Pathway
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & How to Fix Them
  9. New York External Appeal Process
  10. FAQ: Tysabri Coverage in New York

How to Use This Decision Tree

This guide helps you determine whether you qualify for Tysabri coverage through Blue Cross Blue Shield in New York, and what to do next based on your situation. Answer the questions in each section honestly, then follow the corresponding pathway.

Before you start, gather:

  • Your insurance card and member ID
  • Recent MRI reports (within 3 months)
  • List of previous MS medications tried
  • Contact information for your neurologist
  • Any previous denial letters from BCBS

Eligibility Triage: Do You Qualify?

Diagnosis Requirements ✓

Do you have a confirmed diagnosis of relapsing multiple sclerosis?

  • Yes, with recent MRI showing disease activity → Continue
  • Yes, but stable disease → See "Possibly Eligible"
  • No MS diagnosis → See "Not Yet Eligible"
  • Crohn's disease → Different criteria apply (contact your GI specialist)

Prior Therapy Requirements ✓

Have you tried and failed (or have contraindications to) at least one other disease-modifying therapy?

  • Yes, documented failure/intolerance → Continue
  • Currently on first DMT that's failing → See "Possibly Eligible"
  • No prior DMT trials → See "Not Yet Eligible"

TOUCH Program Status ✓

Are you enrolled in the TOUCH Prescribing Program?

  • Yes, all parties enrolled → Continue to "Likely Eligible"
  • Partially enrolled → See "Possibly Eligible"
  • Not enrolled → See "Possibly Eligible"

If "Likely Eligible": Your Next Steps

Congratulations! You meet the basic criteria for Tysabri coverage. Here's your action plan:

Step 1: Complete Required Testing

  • JCV antibody test (if not done in past 6 months)
  • Recent MRI (within 3 months) with radiologist report
  • Complete blood count and liver function tests

Step 2: Ensure TOUCH Enrollment

All parties must be enrolled in the TOUCH Prescribing Program:

  • You (patient)
  • Your neurologist
  • The infusion center
  • The specialty pharmacy

Step 3: Prior Authorization Submission

Your neurologist will submit to BCBS including:

  • Completed prior authorization form
  • Medical necessity letter addressing:
    • MS diagnosis with ICD-10 code
    • Prior DMT failures/contraindications
    • Recent MRI findings
    • JCV antibody status
    • TOUCH enrollment numbers
Tip: Ask your doctor's office to submit via the BCBS provider portal for faster processing (typically 5-7 business days vs. 14 days by fax).

Expected Timeline

  • Standard review: 14 calendar days
  • Expedited review: 72 hours (if urgency documented)
  • Appeals: 30 days for internal, up to 4 months for external

If "Possibly Eligible": Tests and Timeline

You may qualify but need additional documentation. Here's what to track:

Missing Documentation Checklist

  • JCV antibody test results
  • MRI within past 3 months
  • Documentation of current DMT failure
  • TOUCH program enrollment completion
  • Specialist consultation notes

Timeline to Reapply

  • Get missing tests: 2-4 weeks
  • Complete TOUCH enrollment: 1-2 weeks
  • Resubmit PA: Once all requirements met

What to Do Now

  1. Schedule JCV testing immediately
  2. Request recent MRI if needed
  3. Begin TOUCH enrollment process
  4. Document current therapy outcomes with your neurologist

If "Not Yet Eligible": Alternative Options

Don't lose hope. You have several pathways:

Step Therapy Alternatives

Discuss these BCBS-preferred options with your neurologist:

  • Ocrevus (ocrelizumab) - Often first-line for active RRMS
  • Kesimpta (ofatumumab) - Self-injectable alternative
  • Tecfidera (dimethyl fumarate) - Oral option

Exception Request Strategy

Your doctor can request a step therapy override if:

  • You have contraindications to preferred drugs
  • Previous severe adverse reactions documented
  • Unique clinical circumstances warrant Tysabri first-line

Timeline

  • Try preferred therapy: 3-6 months minimum
  • Document failure/intolerance
  • Resubmit Tysabri request with evidence

If Denied: Appeals Pathway

BCBS denials can be overturned. Here's your roadmap:

Level 1: Internal Appeal

  • Deadline: 180 days from denial notice
  • How: Submit reconsideration request with additional clinical evidence
  • Timeline: 30 days for standard, 72 hours for expedited

Level 2: Peer-to-Peer Review

  • Who: Your neurologist speaks directly with BCBS medical director
  • Deadline: Request within 10 days of denial
  • How: Call BCBS provider services to schedule

Level 3: New York External Appeal

  • When: After final internal denial
  • Deadline: 4 months from final adverse determination
  • Cost: $25 (waived for financial hardship)
  • Timeline: 30 days standard, 72 hours expedited, 24 hours for urgent non-formulary drugs
Note: New York's external appeal process has strong consumer protections. Community Health Advocates offers free assistance at 888-614-5400.

Coverage Requirements at a Glance

Requirement Details Where to Find It Source
Prior Authorization Always required BCBS provider portal BCBS PA Guidelines
TOUCH Enrollment Mandatory for all parties touchprogram.com FDA REMS Program
Step Therapy 1+ prior DMT failure Medical records BCBS formulary
JCV Testing Required at baseline, every 6 months if negative Lab results Prescribing Information
MRI Documentation Within 3 months, annual monitoring Radiology reports Clinical guidelines
Specialist Prescriber Neurologist preferred Provider directory BCBS network

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
Missing TOUCH enrollment Complete enrollment for all parties TOUCH confirmation numbers
Inadequate prior therapy documentation Provide detailed medication history Pharmacy records, clinic notes
Missing JCV results Submit current test results Lab report within 6 months
No recent MRI Provide baseline imaging MRI report with radiologist interpretation
Medical necessity question Submit comprehensive letter Neurologist's detailed rationale

New York External Appeal Process

If BCBS upholds their denial, New York offers robust external appeal rights:

When to File

  • After receiving BCBS's final adverse determination
  • For denials based on medical necessity, experimental status, or network issues
  • Within 4 months of final denial

How to File

  1. Download the NYS DFS External Appeal Form
  2. Include all denial letters and supporting medical documentation
  3. Submit with $25 fee (waived for Medicaid or financial hardship)
  4. Mail to: NYS DFS, 99 Washington Avenue, Box 177, Albany, NY 12210

Timeline

  • Standard appeals: 30 days
  • Expedited appeals: 72 hours
  • Non-formulary urgent: 24 hours
From our advocates: We've seen external appeals succeed when providers submit comprehensive clinical evidence showing Tysabri's unique mechanism is necessary for the patient's specific MS phenotype. The key is demonstrating why other DMTs won't achieve the same therapeutic benefit.

FAQ: Tysabri Coverage in New York

Q: How long does BCBS prior authorization take in New York? A: Standard review is 14 calendar days. Expedited review (for urgent cases) is 72 hours. Submit through the provider portal for fastest processing.

Q: What if Tysabri is non-formulary on my BCBS plan? A: Request a formulary exception with medical necessity documentation. If denied, you can appeal through New York's external review process, which has expedited timelines for non-formulary drugs.

Q: Can I get expedited review if I'm having active relapses? A: Yes. Your neurologist must document that delay would seriously jeopardize your health or ability to regain function. Include this in the PA request or appeal.

Q: Does step therapy apply if I tried medications outside New York? A: Yes, documented therapy trials from other states count toward step therapy requirements. Provide pharmacy records and clinical notes from your previous neurologist.

Q: What's the success rate for Tysabri appeals in New York? A: While specific statistics aren't published, well-documented appeals with comprehensive clinical evidence have high success rates, especially when utilizing New York's external review process.

Q: How much does Tysabri cost with BCBS coverage? A: Costs vary by plan. Specialty tier copays typically range from $50-500 per infusion. Check with BCBS member services for your specific benefits. Biogen offers copay assistance programs.

Sources & Further Reading

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies get prescription drugs approved by turning insurance denials into targeted, evidence-backed appeals. Our platform identifies denial reasons and drafts point-by-point rebuttals aligned to each plan's specific requirements, pulling the right medical evidence and weaving it into appeals that meet procedural requirements while tracking deadlines and required documentation.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. For personalized assistance with insurance appeals in New York, contact Community Health Advocates at 888-614-5400 or visit communityhealthadvocates.org.

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