By Counterforce Health Team in Cimzia (certolizumab pegol) —

Get Cimzia Covered by Blue Cross Blue Shield in Pennsylvania: Forms, Appeals & Success Strategies

Answer Box: Getting Cimzia Covered in Pennsylvania

Cimzia (certolizumab pegol) requires prior authorization from Blue Cross Blue Shield plans in Pennsylvania. Your fastest path to approval: 1) Have your doctor submit a PA request through the Availity portal (Highmark) or member-specific system (Independence Blue Cross), 2) Include documentation of diagnosis severity, prior therapy failures, and TB/HBV screening, 3) If denied, use Pennsylvania's new external review program—it overturned 50% of denials in 2024. Start today by calling the member services number on your insurance card to verify your specific PA requirements.

Table of Contents

  1. Start Here: Verify Your Plan & Requirements
  2. Prior Authorization Forms & Documentation
  3. Submission Portals & Electronic Systems
  4. Fax & Mail Submission Details
  5. Specialty Pharmacy Coordination
  6. Support Lines & Case Management
  7. Appeals Process: Internal to External Review
  8. Pennsylvania External Review Program
  9. Common Denial Reasons & Solutions
  10. Cost Support Options

Start Here: Verify Your Plan & Requirements

Before diving into forms and appeals, confirm which Blue Cross Blue Shield plan you have in Pennsylvania. The three major players have different processes:

Highmark Blue Shield (Western/Central PA):

  • Covers ~31% of Pennsylvania's commercial market
  • Requires electronic PA submission via Availity portal as of October 2024
  • Member services: 1-717-302-5000 (Camp Hill), 1-412-544-7000 (Pittsburgh)

Independence Blue Cross (Philadelphia region):

  • Uses plan-specific formularies with step therapy requirements
  • Member services: 1-215-241-2400
  • Customer service medical: 1-800-779-6945

Capital BlueCross (Central PA):

  • General inquiries: 1-717-541-7000
  • Precertification: 1-800-471-2242
Tip: Always use the phone number on your member ID card for the fastest, most accurate information about your specific plan's requirements.

Prior Authorization Forms & Documentation

Coverage Requirements Table

Requirement What It Means Where to Find It Action Needed
Prior Authorization Must get approval before dispensing Plan formulary or member portal Doctor submits PA request
Step Therapy Try cheaper alternatives first Step therapy drug lists Document failures/intolerances
Medical Necessity Clinical justification required PA criteria in plan documents Gather diagnosis, severity evidence
TB/HBV Screening Required safety labs FDA prescribing information Complete screening before request

Required Clinical Documentation

Your prescriber needs to include:

  • Diagnosis with ICD-10 codes (e.g., K50.9 for Crohn's disease, M06.9 for rheumatoid arthritis)
  • Disease severity documentation showing moderate to severe symptoms
  • Prior therapy history including specific medications tried, duration, and reasons for discontinuation
  • Laboratory results including TB screening (chest X-ray, tuberculin skin test or interferon-gamma release assay) and hepatitis B screening
  • Treatment goals and expected clinical outcomes
From our advocates: We've seen PA approvals move much faster when clinics submit a comprehensive packet upfront rather than responding to multiple information requests. One practice reported cutting their average approval time from 3 weeks to 8 days by using a standardized checklist for all Cimzia submissions.

Submission Portals & Electronic Systems

Highmark (Western/Central PA)

Primary portal: Availity (provider login required)

  • Effective October 1, 2024: All medical prior authorizations must be submitted electronically
  • Pharmacy-related authorizations continue through CoverMyMeds platform
  • Forms available at Highmark Provider Resource Center

Independence Blue Cross (Philadelphia)

Submission methods vary by plan type:

  • Standard PA requests through plan-specific provider portals
  • CoverMyMeds for pharmacy benefit drugs
  • Check current submission requirements at IBX provider resources

Electronic Submission Best Practices

  • Create provider accounts before you need them
  • Upload all supporting documents in a single submission
  • Use clear file names (e.g., "Smith_John_Cimzia_PA_LabResults_2024.pdf")
  • Verify member eligibility before submitting

Fax & Mail Submission Details

Fax Numbers (verify current numbers with your plan)

  • Highmark: Provider-specific fax numbers provided through Availity portal
  • BCBS Michigan example: 1-877-325-5979 (for reference—Pennsylvania numbers may differ)
  • Independence Blue Cross: Request fax number through provider relations

Mail Addresses

Highmark Claims: P.O. Box 890062 Camp Hill, PA 17089-0062

Capital BlueCross Claims: P.O. Box 211457 Eagan, MN 55121-3057

Note: Mail submissions typically take 2-3 weeks longer than electronic submissions. Use certified mail for appeals to ensure delivery confirmation.

Specialty Pharmacy Coordination

Cimzia requires specialty pharmacy dispensing due to its storage requirements and administration complexity.

Transfer Process Steps

  1. Verify network pharmacies by calling member services
  2. Contact new specialty pharmacy to initiate prescription transfer
  3. Notify your prescriber about the pharmacy change
  4. Coordinate delivery options (home, office, or clinic)
  5. Arrange injection training if self-administering

Common Specialty Pharmacy Networks

  • CVS Specialty
  • Accredo (Express Scripts)
  • OptumRx Specialty
  • Highmark's preferred specialty pharmacy partners

Companies like Counterforce Health help streamline this process by managing the coordination between your doctor, insurance company, and specialty pharmacy to reduce delays and ensure proper documentation submission.

Support Lines & Case Management

Direct Contact Numbers

Highmark:

  • Case Management: 1-800-207-9309
  • General Provider Relations: 1-717-302-5000

Independence Blue Cross:

  • Customer Service Medical: 1-800-779-6945 (FEHB)
  • Customer Service Medical: 1-844-946-6230 (PSHB)

Capital BlueCross:

  • Case Management: 1-888-320-2583
  • Precertification: 1-800-471-2242

What to Ask When You Call

  • "What are the specific PA criteria for Cimzia for my condition?"
  • "Which prior therapies must I try first under step therapy?"
  • "What clinical documentation is required for approval?"
  • "What's the typical timeline for PA decisions?"
  • "Can I request an expedited review for urgent cases?"

Appeals Process: Internal to External Review

Step-by-Step Appeals Timeline

Level 1: Standard Internal Appeal

  • Timeline: 30 days from denial notice
  • Decision deadline: 15 days (non-urgent), 72 hours (urgent)
  • Required: Written request, clinical documentation, prescriber letter

Level 2: External Review (Pennsylvania)

  • Timeline: 4 months from final internal denial
  • Decision deadline: 45 days (standard), 72 hours (expedited)
  • Success rate: ~50% of denials overturned in 2024

Internal Appeal Requirements

Your appeal letter should include:

  • Member ID and denial reference number
  • Specific reason for appeal (medical necessity, step therapy exception, etc.)
  • Supporting clinical evidence
  • Prescriber attestation letter
  • Relevant medical literature or guidelines

Pennsylvania External Review Program

Pennsylvania launched its Independent External Review Program in January 2024, providing a powerful tool for overturning insurance denials.

Key Statistics

  • 517 external appeals filed in 2024
  • 259 cases overturned in favor of patients (50% success rate)
  • Coverage mandated when IRO rules in patient's favor

Eligibility Requirements

  • Must complete internal appeals process first
  • Applies to medical necessity determinations
  • Available for commercial and marketplace plans (not self-funded employer plans)
  • Must request within 4 months of final internal denial

How to File

Pennsylvania Insurance Department Contact:

  • Phone: 1-877-881-6388
  • Online: Visit PA.gov and search "external review"
  • Mail: Pennsylvania Insurance Department, Consumer Services Bureau, 1326 Strawberry Square, Harrisburg, PA 17120

Common Denial Reasons & Solutions

Denial Reason Solution Strategy Required Documentation
Missing TB/HBV screening Complete required testing Lab results, chest X-ray
Step therapy not met Document failures/intolerances Prior therapy records, adverse events
Insufficient severity Provide detailed clinical evidence Disease activity scores, functional assessments
Non-formulary status Request formulary exception Medical necessity letter, alternative failures
Quantity limits exceeded Justify dosing requirements Weight-based calculations, clinical response

Medical Necessity Letter Checklist

Your prescriber's letter should address:

  • Specific diagnosis with appropriate ICD-10 codes
  • Disease severity and impact on daily functioning
  • Prior treatments attempted with dates and outcomes
  • Clinical rationale for Cimzia selection
  • Expected treatment goals and monitoring plan
  • Relevant guidelines (ACR, ACG, AAD recommendations)

Cost Support Options

Manufacturer Assistance

UCB Cares Patient Assistance Program

  • Copay savings for eligible patients
  • Free drug program for uninsured/underinsured
  • Contact: UCB website patient support

Additional Resources

  • Patient Access Network Foundation: Copay assistance for autoimmune conditions
  • HealthWell Foundation: Financial assistance for specialty medications
  • Pennsylvania CHIP/Medicaid: Income-based coverage for eligible families

Counterforce Health also helps identify and apply for these assistance programs as part of their comprehensive coverage support services.

When to Escalate

Pennsylvania Insurance Department Complaints

File a complaint if your insurer:

  • Fails to meet decision deadlines
  • Requests inappropriate documentation
  • Denies coverage contrary to policy language
  • Violates Pennsylvania insurance regulations

Consumer Services: 1-877-881-6388

Documentation for Complaints

  • Copies of all correspondence
  • Denial letters and appeal responses
  • Timeline of communications
  • Policy language supporting your position

FAQ

How long does Blue Cross Blue Shield PA take in Pennsylvania? Standard prior authorization decisions are made within 15 days for non-urgent requests and 72 hours for urgent requests. Electronic submissions through Availity typically process faster than fax or mail.

What if Cimzia is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and failure of formulary alternatives. Include detailed clinical documentation and prescriber attestation.

Can I request an expedited appeal? Yes, if your condition poses a serious threat to your health. Expedited reviews are decided within 72 hours for internal appeals and external reviews.

Does step therapy apply if I've failed therapies outside Pennsylvania? Yes, prior therapy failures from other states count toward step therapy requirements. Provide complete medical records documenting the previous treatments and outcomes.

What happens if the external review overturns my denial? The insurer must immediately provide coverage as determined by the independent review organization, including retroactive coverage if you paid out-of-pocket during the appeal.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by plan and change frequently. Always verify current requirements with your specific insurer and consult your healthcare provider for medical decisions. For personalized assistance with prior authorizations and appeals, consider working with coverage advocacy services that specialize in insurance navigation.

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