How long does prior authorization take for Pemazyre?

Prior authorization decisions are typically made within 14 calendar days for standard requests, or 72 hours for urgent requests when submitted with complete documentation.

What documentation is required for Pemazyre prior authorization?

Required documentation includes FGFR2 testing results confirming fusion or rearrangement, documentation of prior therapy failures, pathology reports confirming cholangiocarcinoma diagnosis, and current treatment plan from an oncologist.

Can I appeal a Pemazyre coverage denial?

Yes, you can file a formal appeal if Pemazyre is denied. Anthem Virginia allows internal appeals, and if denied, you can request an external review through Virginia's independent review process.

By Counterforce Health Team in Pemazyre (pemigatinib) — 25 Sep 2025

Get Pemazyre (Pemigatinib) Covered by Anthem Blue Cross Blue Shield Virginia: Forms, Appeals & Prior Authorization Guide

Answer Box: Getting Pemazyre (Pemigatinib) Covered in Virginia

Pemazyre (pemigatinib) requires prior authorization from Anthem Blue Cross Blue Shield Virginia for cholangiocarcinoma with FGFR2 fusion. The fastest path: (1) Have your oncologist submit the PA request through Availity's Interactive Care Reviewer portal with FGFR2 testing results and prior therapy documentation, (2) If denied, file an internal appeal within 60 days, (3) Request external review through Virginia's State Corporation Commission Form 216-A within 120 days of final denial.

Start Here: Verify Your Plan & Find the Right Forms
Prior Authorization Forms & Requirements
Submission Portals & Electronic Options
Fax & Mail Submission Details
Appeals Process: Internal & External Review
Common Denial Reasons & How to Fix Them
Virginia State Resources & Consumer Support
Cost Assistance & Patient Support Programs
FAQ: Most Common Questions

Start Here: Verify Your Plan & Find the Right Forms

Before diving into prior authorization, confirm you have Anthem Blue Cross Blue Shield Virginia coverage by checking your insurance card or calling member services at the number on your card. Anthem is Virginia's largest commercial insurer with about 43% market share.

Key Plan Details:

Commercial plans: Most require PA for specialty oncology drugs
Medicaid managed care: Also requires PA through same process
Medicare Advantage: May have different forms and timelines

Tip: If you have a different Blue Cross plan (like CareFirst in Northern Virginia), the forms and processes will be different. Always verify your specific plan first.

Prior Authorization Forms & Requirements

Coverage at a Glance

Requirement	What It Means	Where to Find It	Source
Prior Authorization	Required before dispensing	Anthem PA Updates	Anthem Provider News
FGFR2 Testing	FDA-approved test showing fusion/rearrangement	Your oncology records	FDA Label
Prior Therapy	Previously treated cholangiocarcinoma	Treatment history documentation	Medical records
ICD-10 Code	C22.1 (bile duct cancer) typically	Oncologist's notes	Medical coding

Medical Necessity Requirements

Anthem follows specific criteria for Pemazyre coverage:

Diagnosis: Previously treated, unresectable/metastatic cholangiocarcinoma with FGFR2 fusion or rearrangement detected by FDA-approved test
Prior therapy: Must have received at least one prior systemic treatment
Age: Adult patients (18+ years)
Monitoring plan: Ophthalmologic monitoring for retinal complications

Submission Portals & Electronic Options

Primary Method: Availity Interactive Care Reviewer (ICR)

Fastest processing: Use Anthem's preferred electronic portal at Availity.com.

Requirements:

Provider must register for Availity account
Upload clinical documentation directly
Real-time status tracking available
Auto-authorization for some requests

What to Upload:

Completed PA request form
FGFR2 testing results (molecular pathology report)
Prior therapy documentation
Recent imaging or lab results
Physician's clinical rationale

Note: The ICR portal can handle most specialty drug requests and provides immediate confirmation of submission.

Fax & Mail Submission Details

If electronic submission isn't available, use these backup methods:

Fax Numbers (Current as of 2024)

Medical injectables/oncology drugs: 844-512-7022
Retail pharmacy drugs: 844-512-7020

Required Documentation

Download the Anthem HealthKeepers Plus Pharmacy Prior Authorization Form and complete all sections:

Member Information:

Full name, date of birth
Anthem ID number
Group/employer information

Drug Information:

Pemazyre (pemigatinib) 4.5mg tablets
ICD-10 diagnosis code
HCPCS code (if applicable)
Requested quantity and days supply

Clinical Documentation:

Prior therapies tried and failed
FGFR2 testing results
Medical necessity rationale

Tip: Include a cover sheet with "URGENT - ONCOLOGY DRUG REQUEST" and your contact information for fastest processing.

Appeals Process: Internal & External Review

Step-by-Step: Fastest Path Through Appeals

1. Internal Appeal (Redetermination)

Timeline: File within 60 days of denial notice
Who: Patient, physician, or authorized representative
How: Online portal, fax, or mail (addresses in denial letter)
Decision time: 72 hours standard, 24 hours expedited

2. External Review (Virginia State)

Timeline: File within 120 days of final internal denial
Form: Virginia Form 216-A
Submit to: SCC Bureau of Insurance, P.O. Box 1157, Richmond, VA 23218
Fax: (804) 371-9915
Email: [email protected]

Required Documents for External Review

Completed Form 216-A
Copy of final denial letter
Medical records release form
Copy of insurance card
Any new clinical information

Important: Virginia's external review is binding on the insurer. If approved, Anthem must provide coverage within 1-3 days.

Common Denial Reasons & How to Fix Them

Denial Reason	How to Overturn	Required Documentation
No FGFR2 testing documented	Submit molecular pathology report	FDA-approved test results showing fusion/rearrangement
Insufficient prior therapy	Document treatment history	Chemotherapy records, progression notes
Off-label use concerns	Provide clinical rationale	NCCN guidelines, peer-reviewed studies
Missing ophthalmologic plan	Include monitoring protocol	Ophthalmology consultation plan
Quantity limit exceeded	Justify dosing regimen	Physician attestation for dosing rationale

Clinician Corner: Medical Necessity Letter Checklist

When writing your clinical rationale, include:

Problem statement: Specific diagnosis with staging
Prior treatments: List all therapies tried, dates, and outcomes
Clinical rationale: Why Pemazyre is appropriate now
Guideline support: Reference NCCN, FDA label, or other guidelines
Monitoring plan: How you'll manage side effects
Treatment goals: Expected outcomes and duration

Virginia State Resources & Consumer Support

Virginia State Corporation Commission Bureau of Insurance

Consumer Helpline: 1-877-310-6560 Services:

External review guidance
Appeal process explanation
Form assistance
Complaint filing

Virginia Managed Care Ombudsman

Part of the SCC, specifically helps with HMO and managed care plan issues. Can sometimes resolve disputes informally before formal appeals.

When to Contact Virginia Regulators:

Anthem denies coverage for FDA-approved indication
Appeal deadlines are not being honored
You suspect bad faith claim handling
Need help understanding your rights

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. Their platform helps patients and clinicians navigate complex prior authorization requirements and appeal processes more effectively.

Cost Assistance & Patient Support Programs

Manufacturer Support

Incyte Cares Patient Assistance Program: Financial assistance for eligible patients
Copay savings: May reduce out-of-pocket costs for commercially insured patients
Contact: Visit Incyte's patient support website or call their patient assistance line

Other Resources

Virginia Poverty Law Center: Health assistance for low-income patients
Patient Advocate Foundation: Copay relief and appeal assistance
CancerCare: Financial assistance and counseling services

FAQ: Most Common Questions

Q: How long does Anthem's prior authorization take in Virginia? A: Standard requests: 72 hours. Expedited requests (when delay could harm health): 24 hours. Electronic submissions through Availity are typically fastest.

Q: What if Pemazyre isn't on Anthem's formulary? A: You can request a formulary exception. Your oncologist must provide supporting documentation explaining why covered alternatives aren't appropriate.

Q: Can I get an expedited appeal? A: Yes, if your physician certifies that waiting could seriously jeopardize your health. Virginia also allows expedited external review for cancer treatment denials.

Q: What happens if I start treatment before approval? A: Anthem may deny coverage for services provided without prior authorization. However, pharmacies can dispense up to a 72-hour supply during the review process.

Q: Does Virginia have any special protections for cancer patients? A: Yes, Virginia allows expedited external review for cancer treatment denials without exhausting internal appeals in some cases, reflecting the state's commitment to timely cancer care.

Q: What if my employer plan is self-funded? A: Self-funded plans may opt into Virginia's external review process. If not, you may have federal external review through HHS. The Bureau of Insurance can help determine which applies.

Q: How often should I check for updated forms and requirements? A: Check quarterly, as Anthem updates prior authorization requirements regularly. Provider news bulletins announce changes with effective dates.

Q: What's the success rate for appeals in Virginia? A: Virginia doesn't publish specific success rates, but having complete clinical documentation and following proper procedures significantly improves outcomes. Counterforce Health has seen improved success rates by ensuring appeals address the specific denial reasons with targeted evidence.

From Our Advocates: We've seen many Pemazyre approvals succeed on appeal when the initial request was denied for "insufficient documentation." The key is often ensuring the FGFR2 testing report clearly states the specific fusion type and that prior therapy records show clear progression or intolerance. Don't assume the reviewer will connect the dots—spell out exactly why this patient needs this specific drug now.

Disclaimer: This information is for educational purposes and doesn't constitute medical or legal advice. Insurance policies and state regulations can change. Always verify current requirements with your insurer and consult healthcare professionals for medical decisions.

Sources & Further Reading

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