By Counterforce Health Team in Jaypirca (pirtobrutinib) —

Get Jaypirca (Pirtobrutinib) Covered by Blue Cross Blue Shield in Florida: Complete Coding, Appeals & Forms Guide 2024

Answer Box: Getting Jaypirca (Pirtobrutinib) Covered in Florida

Jaypirca (pirtobrutinib) requires prior authorization from Blue Cross Blue Shield in Florida for relapsed/refractory mantle cell lymphoma or CLL/SLL after BTK inhibitor failure. Submit PA requests via Availity.com with proper ICD-10 codes (C83.1 for MCL, C91.10-C91.12 for CLL), documented prior therapy failures, and HCPCS J8999 for oral formulation. If denied, file internal appeals within 180 days, then external review through Florida's Department of Financial Services. First step today: Confirm your exact Blue Cross Blue Shield plan and check formulary status at your member portal.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping for Jaypirca
  3. Product Coding: HCPCS, J-Codes, and NDC
  4. Clean Prior Authorization Request
  5. Frequent Billing Pitfalls
  6. Verification with Blue Cross Blue Shield Florida
  7. Appeals Process in Florida
  8. Quick Audit Checklist
  9. FAQ

Coding Basics: Medical vs. Pharmacy Benefit

Jaypirca (pirtobrutinib) is typically covered under the pharmacy benefit for Blue Cross Blue Shield plans in Florida, not the medical benefit. This matters because:

  • Pharmacy benefit: Uses NDC codes, requires pharmacy prior authorization, subject to formulary tiers and quantity limits
  • Medical benefit: Would use HCPCS J-codes for injectable versions (currently not applicable for oral Jaypirca)
Note: Florida Blue processes most oral oncology medications through their pharmacy benefit manager, Prime Therapeutics. Confirm your specific plan's structure before submitting claims.

ICD-10 Mapping for Jaypirca

Proper diagnosis coding is critical for Jaypirca approval. Use these specific ICD-10-CM codes:

Coverage at a Glance

Indication ICD-10 Code Description Documentation Required
Mantle Cell Lymphoma C83.1 Mantle cell lymphoma, unspecified site Pathology confirming cyclin D1+, prior BTK inhibitor failure
CLL (active) C91.10 Chronic lymphocytic leukemia of B-cell type not having achieved remission Flow cytometry (CD5+, CD23+), ≥2 prior therapies including BTK inhibitor
CLL (relapsed) C91.12 Chronic lymphocytic leukemia of B-cell type, in relapse Documented progression after prior remission
Small Lymphocytic Lymphoma C83.00 Small cell B-cell lymphoma, unspecified site Biopsy confirmation, prior treatment history

Documentation Words That Support Coding

When submitting prior authorization requests, include these specific terms in clinical notes:

  • For relapsed disease: "progression after," "disease recurrence," "radiographic progression," "new lesions"
  • For refractory disease: "failed to respond," "primary resistance," "no complete response," "stable disease only"
  • Prior therapy documentation: "intolerant to ibrutinib due to," "discontinued acalabrutinib for," "progression on zanubrutinib"

Product Coding: HCPCS, J-Codes, and NDC

HCPCS/J-Code Information

  • Primary code: J8999 (oral oncology medication, unclassified)
  • Alternative: J9399 (if injectable formulation becomes available)
  • Billing units: Per tablet dispensed (not per mg)

Dosing and Units Calculation

Standard dosing: 200 mg once daily = 2 tablets of 100 mg OR 4 tablets of 50 mg

Monthly supply calculation:

  • 30-day supply = 60 tablets (100 mg) or 120 tablets (50 mg)
  • Always bill actual tablets dispensed, not total milligrams

NDC Numbers

NDC numbers vary by manufacturer lot and should be verified at time of dispensing. Check the FDA National Drug Code Directory for current NDC assignments.

Clean Prior Authorization Request

Step-by-Step: Fastest Path to Approval

  1. Gather documentation (1-2 days)
    • Complete pathology reports with immunohistochemistry
    • Prior therapy timeline with dates and reasons for discontinuation
    • Current staging scans and lab values
  2. Submit PA via Availity (same day)
    • Log into Availity.com provider portal
    • Complete Florida Blue prior authorization form
    • Attach all supporting documentation
  3. Follow up within 72 hours
    • Call Florida Blue at 1-877-719-2583 to confirm receipt
    • Request expedited review if clinically urgent
  4. Prepare for peer-to-peer (if initial denial)
    • Have prescribing physician available for medical review
    • Prepare clinical rationale with guideline references

Medical Necessity Letter Checklist

When writing medical necessity letters for Jaypirca, include:

✓ Patient problem: Specific diagnosis with staging ✓ Prior treatments: Complete list with dates, responses, and reasons for discontinuation
✓ Clinical rationale: Why Jaypirca is appropriate (non-covalent BTK inhibitor, active against C481S mutations) ✓ Guideline citations: Reference NCCN Guidelines for MCL or CLL/SLL ✓ Dosing plan: 200 mg daily with monitoring schedule ✓ Monitoring plan: CBC, comprehensive metabolic panel, assessment schedule

Clinician Corner: Include FDA label language about accelerated approval based on overall response rate. For CLL/SLL, emphasize that continued approval is contingent on confirmatory trials, which supports medical necessity for eligible patients.

Frequent Billing Pitfalls

Common Denial Reasons & Fixes

Denial Reason How to Fix Required Documentation
Insufficient prior therapy documentation Provide detailed treatment timeline Clinic notes, pharmacy records, prior auth approvals
Missing BTK inhibitor failure evidence Submit progression scans, lab values Imaging reports, CBC trends, physician notes
Incorrect units billing Resubmit with per-tablet calculation Prescription showing exact tablet count
Non-specialty pharmacy Transfer to approved specialty pharmacy Florida Blue specialty pharmacy network list
Quantity limit exceeded Request override with clinical justification Letter explaining medical necessity for quantity

Unit Conversion Errors

Correct: Bill 60 units for 30-day supply (2 × 100-mg tablets daily) Incorrect: Bill 6000 units (200 mg × 30 days)

Always calculate based on tablets dispensed, not total milligrams per month.

Verification with Blue Cross Blue Shield Florida

Pre-Submission Checklist

Before submitting your Jaypirca prior authorization:

  1. Verify patient eligibility
    • Check active coverage at FloridaBlue.com member portal
    • Confirm pharmacy benefit details
  2. Check formulary status
  3. Confirm submission method
    • Most requests via Availity.com
    • Some plans accept fax submissions (verify current fax number)
  4. Prepare for expedited review if needed
    • Document clinical urgency
    • Have physician available for peer-to-peer discussion

Appeals Process in Florida

If your initial prior authorization is denied, Florida provides multiple appeal levels:

Internal Appeal Process

Timeline: File within 180 days of denial notice Method: Submit via Florida Blue appeals form or member portal Resolution: 30 days for standard appeals, 24 hours for expedited

External Review Process

When to use: After failed internal appeal Timeline: Request within 4 months of final internal denial Authority: Florida Department of Financial Services Contact: 1-877-693-5236 Cost: No charge to patient Resolution: 45 days standard, 72 hours expedited

Escalation Resources

For assistance with appeals in Florida:

Quick Audit Checklist

Before submitting any Jaypirca request:

Patient Information

  • Correct member ID and group number
  • Active coverage verified
  • Prior authorization required confirmed

Clinical Documentation

  • Appropriate ICD-10 code (C83.1, C91.10-C91.12, or C83.00)
  • Pathology/flow cytometry reports attached
  • Prior BTK inhibitor therapy documented with outcomes
  • Current disease status confirmed with imaging/labs

Coding and Billing

  • Correct HCPCS code (J8999 for oral)
  • Accurate tablet count calculation
  • NDC number verified
  • Prescribing physician NPI included

Submission Details

  • Submitted via correct portal (Availity for most plans)
  • All required forms completed
  • Supporting documentation attached
  • Follow-up plan established

FAQ

How long does Blue Cross Blue Shield prior authorization take in Florida? Standard prior authorizations are processed within 30 days, but Florida Blue's AI system processes 90% of requests with a median time of 19 seconds for automated approvals.

What if Jaypirca is non-formulary on my plan? Request a formulary exception through the Coverage Exception Request process. Include documentation of medical necessity and prior therapy failures.

Can I request an expedited appeal? Yes, if there's immediate health jeopardy or you're currently receiving treatment. Call 1-800-926-6565 for expedited appeals.

Does step therapy apply if I failed BTK inhibitors outside Florida? Florida law recognizes out-of-state trials within 90 days. Provide documentation of prior therapy attempts regardless of location.

What's the difference between internal and external appeals? Internal appeals are reviewed by your insurance company. External appeals are reviewed by independent medical experts contracted by the state of Florida.

How much does Jaypirca cost without insurance? Cash prices typically range from $22,500-$26,000 per month. Check with Eli Lilly for patient assistance programs.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals that align with payer requirements, pulling the right clinical evidence and procedural details to improve approval rates.

For complex Jaypirca appeals or assistance with Blue Cross Blue Shield denials, Counterforce Health provides specialized support to navigate payer-specific workflows and improve approval outcomes.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and coverage requirements may vary. Always consult with your healthcare provider and insurance company for specific coverage decisions. For assistance with insurance complaints in Florida, contact the Florida Department of Financial Services at 1-877-693-5236.

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