How long does Blue Cross Blue Shield Florida prior authorization take for Pemazyre?

Blue Cross Blue Shield of Florida typically processes Pemazyre prior authorization requests within 5-15 business days for standard requests. Urgent requests may be processed faster with appropriate clinical justification.

What documentation is required for Pemazyre prior authorization with BCBS Florida?

Required documentation includes: confirmed FGFR2 fusion/rearrangement testing results, pathology report confirming cholangiocarcinoma diagnosis, documentation of prior therapy attempts, baseline ophthalmologic examination results, and completed prior authorization form.

Can I appeal a Pemazyre coverage denial from Blue Cross Blue Shield Florida?

Yes, you have the right to appeal a Pemazyre coverage denial from BCBS Florida. The appeal process includes internal appeals (peer-to-peer review, formal appeal) and external appeals through the Florida Office of Insurance Regulation if internal appeals are unsuccessful.

What is the cost of Pemazyre without insurance coverage?

Pemazyre typically costs $15,000-20,000 per month without insurance coverage. Patient assistance programs through Incyte and co-pay assistance programs may be available to help reduce out-of-pocket costs.

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

Get Pemazyre (Pemigatinib) Covered by Blue Cross Blue Shield in Florida: Complete PA Guide with Forms and Appeals

Name: Get Pemazyre (Pemigatinib) Covered by Blue Cross Blue Shield in Florida: Complete PA Guide with Forms and Appeals
Creator: Counterforce Health
Published: 2025-12-25

Answer Box: Quick Path to Pemazyre Coverage in Florida

Blue Cross Blue Shield of Florida requires prior authorization for Pemazyre (pemigatinib) based on confirmed FGFR2 fusion/rearrangement testing, prior therapy documentation, and baseline eye exam. Submit PA via Florida Blue provider portal or fax 1-904-348-3295 with genetic test results, pathology report, and ophthalmologic monitoring plan. Processing takes 5-15 business days; expedited review available in 72 hours for urgent cases. If denied, file internal appeal within 180 days, then external review through Florida DFS within 4 months.

First step today: Confirm FGFR testing is complete and schedule baseline OCT eye exam while your oncologist gathers prior therapy records.

Coverage Requirements at a Glance
Step-by-Step: Fastest Path to Approval
Common Denial Reasons & How to Fix Them
Appeals Playbook for Florida Blue
Clinician Corner: Medical Necessity Documentation
Costs & Patient Support Options
When to Escalate to State Regulators
Frequently Asked Questions

Coverage Requirements at a Glance

Requirement	What It Means	Where to Find It	Source
Prior Authorization	Required for all Pemazyre prescriptions	Member portal or call 1-800-926-6565	Florida Blue PA Info
Formulary Tier	Tier 3 Non-Preferred Brand or Specialty Tier	2025 formulary guides	Florida Blue Formulary
FGFR Testing	FGFR2 fusion for cholangiocarcinoma; FGFR1 rearrangement for myeloid neoplasms	FDA-approved companion diagnostic	FDA Label
Prior Therapy	Disease progression on/intolerance to prior treatment	Chart notes, imaging, pathology	Florida Blue PA Criteria
Eye Monitoring	Baseline OCT exam before starting	Ophthalmology consultation	Pemazyre Prescribing Info
Appeals Deadline	180 days for internal; 4 months for external	Denial notice	Florida Blue External Review

Step-by-Step: Fastest Path to Approval

1. Confirm Eligibility Requirements

Who does it: Patient and oncologist
What's needed: Review diagnosis and testing status

Confirmed cholangiocarcinoma with FGFR2 fusion/rearrangement OR myeloid/lymphoid neoplasm with FGFR1 rearrangement
Disease progression on prior therapy (typically gemcitabine-based chemotherapy)
No prior FGFR inhibitor treatment Timeline: Same day

2. Complete Required Testing

Who does it: Oncologist orders, patient completes
What's needed:

FGFR genetic testing via FDA-approved companion diagnostic if not already done
Baseline ophthalmologic exam with OCT imaging
Document any contraindications to alternative therapies Timeline: 7-14 days for genetic results; 1-2 weeks for eye appointment

3. Gather Documentation Package

Who does it: Clinic staff
What's needed:

Pathology report confirming diagnosis with staging
Genetic test results showing FGFR alteration
Prior therapy records with response/progression imaging
Baseline eye exam with OCT results
Current performance status and lab values Timeline: 2-3 days to compile

4. Submit Prior Authorization

Who does it: Prescribing oncologist
How to submit: Florida Blue provider portal or fax 1-904-348-3295
Required forms: Include all documentation package items
Timeline: 5-15 business days standard; 72 hours if marked urgent

5. Follow Up on Decision

Who does it: Clinic staff or patient
What to track: PA approval number and any conditions/limitations
If approved: Coordinate with specialty pharmacy for drug delivery
If denied: Proceed immediately to appeals process
Timeline: Decision notification within stated timeframes

Common Denial Reasons & How to Fix Them

Denial Reason	How to Overturn	Required Documentation
No documented FGFR alteration	Submit complete genetic testing report from CLIA-certified lab	NGS panel or FISH results showing specific fusion/rearrangement
Insufficient prior therapy	Provide detailed treatment history with progression evidence	Imaging reports, oncologist notes, treatment timelines
Missing eye monitoring plan	Submit ophthalmology consultation with baseline OCT	Complete eye exam report with monitoring schedule
Off-label use concerns	Cite FDA approval and NCCN guidelines	FDA indication and guideline references
Step therapy not completed	Request step therapy exception with medical necessity letter	Contraindication documentation or prior failure outside network

From our advocates: We've seen approvals turn around quickly when oncologists include a clear timeline showing disease progression despite standard chemotherapy, paired with the specific FGFR alteration report. The key is connecting the dots between the patient's molecular profile and why Pemazyre is the medically appropriate next step.

Appeals Playbook for Florida Blue

Internal Appeal (First Level)

Deadline: 180 days from denial notice
How to file: Written request via member portal, mail, or fax
Required: Denial notice, additional medical records, physician letter
Timeline: 15 days for pre-service; 30 days for post-service; 72 hours if urgent
Contact: Appeals and Disputes, PO Box 44197, Jacksonville, FL 32231-4197

Expedited Internal Appeal

When to use: Delay would jeopardize life, health, or recovery
Timeline: 72 hours maximum
Required: Physician certification of urgency
Submission: Same as standard but mark "URGENT" clearly

External Review (Final Level)

Deadline: 4 months after final internal denial
Process: Submit Florida Blue External Review Request Form
Timeline: 45 days standard; 72 hours expedited
Cost: Free to patient
Decision: Binding on Florida Blue if overturned

Key tip: For oncology cases, always request expedited review when appropriate. Disease progression doesn't wait for standard timelines.

Clinician Corner: Medical Necessity Documentation

Essential Elements for PA Success

Diagnosis specificity: "Unresectable, locally advanced cholangiocarcinoma with confirmed FGFR2 fusion via FoundationOne CDx testing"
Prior therapy details: Specific regimens tried, dates, best response, reason for discontinuation
Molecular rationale: Explain why FGFR targeting is appropriate for this patient's tumor biology
Safety monitoring: Detail ophthalmologic monitoring plan per prescribing information

Medical Necessity Letter Template Points

Reference FDA approval for specific indication
Cite NCCN Guidelines supporting use in FGFR-altered tumors
Document contraindications to alternative therapies if applicable
Include performance status and life expectancy considerations
Attach genetic testing report and pathology confirmation

Counterforce Health helps oncologists streamline this documentation process by automatically generating evidence-backed appeals that align with Florida Blue's specific criteria, saving valuable time while improving approval rates.

Costs & Patient Support Options

Manufacturer Support

Incyte Cares: Patient assistance program for eligible uninsured/underinsured patients
Copay assistance: May reduce out-of-pocket costs for commercially insured patients
Contact: Visit Incyte Cares website or call patient support

Foundation Assistance

CancerCare Co-Payment Assistance Foundation
Patient Advocate Foundation
Leukemia & Lymphoma Society (for myeloid neoplasms)

Florida-Specific Resources

Florida Blue may offer temporary supply during appeals process
Check member benefits for specialty pharmacy coverage options

When to Escalate to State Regulators

Contact the Florida Department of Financial Services if:

Florida Blue fails to meet appeal deadlines
You're denied expedited review for urgent cases
The appeals process isn't followed properly

Florida Insurance Consumer Helpline: 1-877-693-5236
Online complaint: Florida DFS Consumer Services

The state can facilitate communication and ensure you receive full appeal rights under Florida law.

Frequently Asked Questions

Q: How long does Florida Blue prior authorization take for Pemazyre?
A: Standard PA processing is 5-15 business days. Expedited requests for urgent cases are decided within 72 hours when properly documented.

Q: What if Pemazyre isn't on my specific Florida Blue formulary?
A: Request a formulary exception using the Coverage Exception Request form. Include medical necessity documentation showing covered alternatives are inappropriate.

Q: Can I get expedited appeals for cancer treatment delays?
A: Yes. If treatment delay would jeopardize your health, request expedited internal and external review simultaneously. Your oncologist must certify the urgency.

Q: Does step therapy apply if I failed chemotherapy outside Florida?
A: Prior therapy from any provider counts toward step therapy requirements. Provide complete treatment records from previous oncologists.

Q: What's the success rate for Pemazyre appeals in Florida?
A: External review success rates vary, but oncology appeals with proper molecular testing documentation and medical necessity letters typically have favorable outcomes when criteria are met.

Q: Do I need to use a specific specialty pharmacy?
A: Yes, Florida Blue requires use of their contracted specialty pharmacy network (typically Accredo or CVS Specialty) for coverage. Out-of-network pharmacies result in higher costs.

Q: What if my eye exam shows problems during treatment?
A: Follow the dose modification guidelines in the prescribing information. Your oncologist may need to hold, reduce, or discontinue Pemazyre based on ophthalmologic findings.

Q: Can I appeal to Medicare if I have a Florida Blue Medicare plan?
A: Medicare Advantage plans follow Medicare appeal rules, which include redetermination and reconsideration levels before external review. Check your specific plan documents for the correct process.

Sources & Further Reading

For complex cases involving multiple denials or unusual circumstances, Counterforce Health specializes in turning insurance denials into successful appeals by creating targeted, evidence-backed submissions that align with each payer's specific requirements.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and coverage criteria can change frequently. Always verify current requirements with Florida Blue directly and consult with your healthcare team for medical decisions. For personalized assistance with insurance appeals, contact the Florida Department of Financial Services or consider working with a qualified patient advocate.

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