By Counterforce Health Team in Besponsa (inotuzumab ozogamicin) —

Get Besponsa (Inotuzumab Ozogamicin) Covered by Blue Cross Blue Shield in Virginia: Forms, Appeals & Provider Portals

Answer Box: Getting Besponsa Covered by Blue Cross Blue Shield in Virginia

Besponsa (inotuzumab ozogamicin) requires prior authorization from Blue Cross Blue Shield in Virginia through their medical injectable pharmacy channel. Your fastest path to approval: (1) Verify CD22+ B-cell precursor ALL diagnosis with proper documentation, (2) Submit prior auth via fax to 844-512-7022 with clinical notes showing relapsed/refractory status, and (3) Enroll with preferred specialty pharmacy (Accredo/CVS Specialty) for direct office delivery. If denied, Virginia's Bureau of Insurance provides external review within 120 days using Form 216-A.

Table of Contents

  1. Start Here: Verify Your Plan & Coverage
  2. Prior Authorization Forms & Requirements
  3. Submission Portals & Digital Tools
  4. Fax Numbers & Mailing Addresses
  5. Specialty Pharmacy Setup
  6. Support Lines & Who to Call
  7. Virginia Appeals Process & External Review
  8. Common Denial Reasons & Solutions
  9. Frequently Asked Questions

Start Here: Verify Your Plan & Coverage

Before requesting Besponsa coverage, confirm your specific Blue Cross Blue Shield plan details. Virginia's primary BCBS carrier is Anthem Blue Cross Blue Shield (HealthKeepers, Inc.), but coverage policies vary by plan type.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Besponsa requests Anthem Virginia PA Requirements
CD22+ Documentation Must confirm CD22 protein on B-cell surface Clinical pathology report
Formulary Status Specialty tier, medical benefit Member portal or ID card phone number
Site of Care Physician office administration preferred Plan policy documents
Appeals Deadline 120 days for external review in Virginia Virginia SCC Bureau of Insurance

First step today: Call the member services number on your insurance card to verify your specific plan's formulary status and prior authorization requirements for Besponsa.

Prior Authorization Forms & Requirements

Medical Necessity Criteria

Besponsa approval requires documentation of:

  • B-cell precursor acute lymphoblastic leukemia (ALL) diagnosis
  • CD22-positive disease confirmed through testing (≥20% of lymphoblasts minimum for most clinical contexts)
  • Relapsed or refractory disease after prior therapy
  • Philadelphia chromosome status (negative, or failed tyrosine kinase inhibitor if positive)
Clinician Corner: Your medical necessity letter should include ICD-10 codes, prior treatment history with specific agents and outcomes, CD22 expression percentage from pathology, and monitoring plan for hepatotoxicity/veno-occlusive disease per FDA boxed warning.

Required Documentation

Submit these documents with your prior authorization:

  1. Completed prior authorization form (plan-specific)
  2. Clinical notes documenting ALL diagnosis and disease status
  3. Pathology report confirming CD22 positivity
  4. Treatment history showing prior therapies and outcomes
  5. Prescriber attestation of medical necessity

Submission Portals & Digital Tools

Anthem Blue Cross Blue Shield Virginia

Primary digital submission method:

  • Interactive Care Reviewer (ICR) via Availity portal
  • Login at Availity Essentials → Patient Registration tab
  • Auto-authorization available for some procedures; specialty drugs require full review

Provider verification steps:

  1. Check Prior Authorization Lookup Tool before rendering services
  2. Access formulary and pharmacy prior authorization forms on Pharmacy Information page
  3. Submit pregnancy notifications via ICR if relevant to patient

Fax Numbers & Mailing Addresses

Anthem Blue Cross Blue Shield Virginia Fax Numbers

Service Type Fax Number
Medical Injectable (Besponsa) 844-512-7022
Retail Pharmacy 844-512-7020
General Medical Outpatient 800-964-3627
Expedited Requests 888-235-8390

HealthKeepers Plus (Virginia Medicaid)

  • Provider Services: 800-901-0020 (TTY: 711)
Tip: Include a detailed cover sheet with member ID, drug name (generic and brand), diagnosis codes, and urgency level. Fax during business hours when possible for faster processing.

Specialty Pharmacy Setup

Besponsa requires special handling (refrigeration, limited distribution) through preferred specialty pharmacies for cost-effective access and proper administration support.

Preferred Specialty Pharmacies

Primary options for BCBS Virginia members:

  • Accredo by Evernorth: 833-721-1619 (commercial plans)
  • CVS Specialty: 800-237-2767, fax 800-323-2445
  • Prime Therapeutics Specialty

Onboarding Process

  1. Provider enrollment: Submit credentialing applications with DEA registration and board certification
  2. Patient enrollment: Specialty pharmacy contacts member for delivery setup and education
  3. Prescription routing: E-prescribe or fax to designated pharmacy post-enrollment
  4. Delivery coordination: Pharmacy delivers to office, bills BCBS directly
Note: Providers bill for administration only (not drug cost) under buy-and-bill arrangements. Verify delivery location and refrigeration requirements with pharmacy.

Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements by analyzing denial letters and drafting evidence-backed appeals. Their platform identifies specific denial reasons and creates point-by-point rebuttals aligned to each plan's policies, streamlining the approval process for specialty medications like Besponsa.

Support Lines & Who to Call

Member Services

  • General inquiries: Number on your insurance ID card
  • Prior authorization status: Same number, request transfer to utilization management

Provider Services

  • Anthem Virginia: Check provider manual or contact via Availity portal
  • Clinical questions: Request peer-to-peer review through prior authorization department

What to Ask When Calling

  1. "What's the current prior authorization status for [member name, DOB]?"
  2. "What additional documentation is needed for approval?"
  3. "Can we schedule a peer-to-peer review with the medical director?"
  4. "What's the appeals process if this request is denied?"

Virginia Appeals Process & External Review

Internal Appeals Timeline

  1. Level 1: 30-60 days for standard review, 72 hours for expedited
  2. Level 2: Additional internal review if available under plan

External Review with Virginia Bureau of Insurance

When to file: After exhausting internal appeals or if insurer doesn't respond within required timeframes

Form 216-A Requirements:

  • Submit within 120 days of final denial
  • Include signed medical records release
  • Attach insurance card copy and denial letter
  • Provide any new clinical information

Submit to: State Corporation Commission, Bureau of Insurance – External Review
P.O. Box 1157, Richmond, VA 23218
Phone: 1-877-310-6560
Email: [email protected]

Timeline: Independent review organization has maximum 10 days for standard review, 72 hours for expedited emergency cases.

Virginia Advantage: External review is provided free of charge, and the Bureau's decision is binding on your insurer. For urgent cases, you may request expedited external review while simultaneously filing urgent care appeals.

Common Denial Reasons & Solutions

Denial Reason How to Overturn
CD22 status not documented Submit pathology report with specific CD22 expression percentage
Line of therapy unclear Provide detailed treatment history with dates, agents, and outcomes
Hepatic risk not addressed Include hepatic function tests and monitoring plan per FDA label
Dosing outside label Cite clinical guidelines supporting dose modifications if applicable
Step therapy not completed Document contraindications or failures of required prior therapies

When Counterforce Health Can Help

If you receive a denial, Counterforce Health specializes in turning insurance denials into targeted appeals. Their platform ingests denial letters and clinical notes to identify the specific denial basis, then drafts point-by-point rebuttals with the right evidence citations and clinical facts required for successful appeals.

Frequently Asked Questions

Q: How long does BCBS prior authorization take in Virginia?
A: Standard reviews take 30-60 days; expedited reviews for urgent cases are completed within 72 hours. Submit complete documentation to avoid delays.

Q: What if Besponsa is non-formulary on my plan?
A: Request a formulary exception with medical necessity documentation. Virginia law requires insurers to have an exception process for non-formulary medications.

Q: Can I request an expedited appeal?
A: Yes, if your physician certifies that waiting could seriously jeopardize your health. Virginia offers expedited external reviews within 72 hours for urgent cases.

Q: Does step therapy apply if I failed therapies in another state?
A: Yes, documented treatment failures from any location should count toward step therapy requirements. Provide complete medical records.

Q: What happens if external review upholds the denial?
A: The insurer won't be required to cover the medication, but you retain rights to pursue other options like employer appeals (for self-funded plans) or legal consultation.

Q: Are there financial assistance programs for Besponsa?
A: Pfizer offers patient assistance programs. Contact Pfizer Patient Assistance at 1-844-989-7284 or visit their website for eligibility requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Coverage policies vary by plan and change frequently. Always verify current requirements with your insurer and consult your healthcare provider for medical decisions. For personalized assistance with Virginia insurance appeals, contact the State Corporation Commission Bureau of Insurance at 1-877-310-6560.

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