By Counterforce Health Team in Pemazyre (pemigatinib) —

Get Pemazyre (Pemigatinib) Covered by Blue Cross Blue Shield in Washington: Prior Authorization Forms, Appeal Deadlines & Success Strategies

Answer Box: Getting Pemazyre Covered in Washington

Pemazyre (pemigatinib) requires prior authorization from Blue Cross Blue Shield plans in Washington. Success depends on documenting FGFR2 fusion/rearrangement, prior therapy failure, and an ophthalmic monitoring plan. If denied, Washington's external review process through an Independent Review Organization (IRO) provides binding decisions within 15-20 days.

First steps: Confirm your plan type, gather biomarker test results and treatment history, then submit the specialty drug PA form through your provider. Appeals must be filed within 60 days of denial.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Plan Verification
  3. Gather Required Documentation
  4. Submit the Prior Authorization Request
  5. Follow-Up and Tracking
  6. Common Denial Reasons & Solutions
  7. Appeals Process in Washington
  8. Costs and Financial Assistance
  9. Renewal and Reauthorization
  10. FAQ

What This Guide Covers

This guide helps patients with cholangiocarcinoma or myeloid/lymphoid neoplasms (MLNs) navigate the prior authorization process for Pemazyre (pemigatinib) with Blue Cross Blue Shield plans in Washington state. We'll walk through the specific requirements, forms, timelines, and appeal options available to Washington residents.

Pemazyre is an oral FGFR inhibitor approved for adults with locally advanced or metastatic cholangiocarcinoma with FGFR2 fusion/rearrangement who have received at least one prior therapy, and for relapsed/refractory MLNs with FGFR1 rearrangement. The medication requires specialty pharmacy distribution and comprehensive ophthalmic monitoring due to retinal risks.

Note: This guide applies to Washington residents with Blue Cross Blue Shield coverage, including Premera Blue Cross and Regence BlueShield plans.

Before You Start: Plan Verification

Step 1: Confirm Your Coverage Type

  • Commercial plans: Standard PA process applies
  • Medicare Advantage: May have additional requirements
  • Medicaid (Apple Health): Different appeal process through fair hearings

Step 2: Verify Pemazyre's Formulary Status

Most Blue Cross Blue Shield plans in Washington classify Pemazyre as a specialty tier drug requiring prior authorization. Contact your plan's pharmacy services to confirm:

  • Premera Blue Cross: 888-261-1756
  • Regence BlueShield: Check your plan documents or member portal

Step 3: Confirm Specialty Pharmacy Network

Pemazyre is distributed only through designated specialty pharmacies, typically Biologics by McKesson or ASD Healthcare for 340B entities. Your provider will need to coordinate with these pharmacies, not retail locations.

Gather Required Documentation

Medical Necessity Criteria Checklist

  • Diagnosis confirmation: Unresectable locally advanced or metastatic cholangiocarcinoma OR relapsed/refractory MLNs
  • Biomarker testing: FGFR2 fusion/rearrangement (cholangiocarcinoma) or FGFR1 rearrangement (MLNs) via validated test
  • Prior therapy documentation: At least one prior systemic therapy with progression
  • Ophthalmic baseline: Comprehensive eye exam with OCT completed
  • Monitoring plan: Schedule for every 2 months (first 6 months), then every 3 months

Documentation to Collect

  1. Pathology reports showing cholangiocarcinoma or MLN diagnosis
  2. Molecular testing results confirming FGFR alteration
  3. Treatment history with dates, medications, and progression documentation
  4. Baseline ophthalmology exam with OCT results
  5. Current imaging showing disease status
  6. ICD-10 codes: C22.1 (cholangiocarcinoma) or relevant MLN codes

Submit the Prior Authorization Request

For Premera Blue Cross

  1. Download the PA form from the Premera provider portal
  2. Submit via fax: 888-260-9836
  3. Include all supporting documentation in one complete packet
  4. Follow up within 72 hours to confirm receipt

For Regence BlueShield

  1. Access forms through your plan's drug list materials
  2. Submit per plan instructions (typically fax or provider portal)
  3. Ensure complete clinical documentation accompanies the request
Clinician Corner: The medical necessity letter should explicitly state the FGFR alteration type, prior therapy failures with dates, and rationale for why alternative treatments are inappropriate. Include references to FDA labeling and relevant oncology guidelines.

Follow-Up and Tracking

Standard Review Timelines

  • Initial decision: 72 hours for standard requests
  • Urgent requests: 24-48 hours
  • Emergency override: Up to 7-day supply available through specialty pharmacy

What to Track

  • Reference numbers from all submissions
  • Decision deadlines based on your plan's requirements
  • Contact information for the assigned case manager

Sample Follow-Up Script

"I'm calling to check on the status of prior authorization request #[number] for Pemazyre submitted on [date]. Can you confirm receipt and provide an expected decision timeline?"

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
No FGFR alteration documented Submit validated test results Molecular pathology report
Insufficient prior therapy Provide detailed treatment history Progress notes, imaging
Missing ophthalmic monitoring Submit baseline exam and monitoring plan OCT results, ophthalmology consult
Off-label use Demonstrate medical necessity Literature supporting use
Step therapy not completed Request exception based on contraindications Clinical rationale letter

Appeals Process in Washington

Washington state provides robust appeal rights through the Office of the Insurance Commissioner, including access to Independent Review Organizations (IROs).

Internal Appeals

  1. File within 60 days of denial letter date
  2. Submit to your insurer with additional documentation
  3. Receive decision within plan timelines (typically 30 days)

External Review (IRO)

If internal appeals fail, Washington residents can request external review:

  1. File within 60 days of final internal denial
  2. Submit to your insurer who forwards to the assigned IRO
  3. Provide additional information within 5 business days to the IRO
  4. Receive binding decision within 15-20 days for standard review, 72 hours for expedited
Important: The IRO decision is binding on your insurer. If they overturn the denial, coverage must be provided.

Washington Insurance Commissioner Resources

  • Consumer Advocacy: 1-800-562-6900
  • Appeal guidance: insurance.wa.gov
  • Template letters: Available on the OIC website
From our advocates: We've seen Washington patients succeed with IRO appeals by submitting comprehensive clinical timelines and highlighting how Pemazyre aligns with FDA-approved indications. The key is presenting a clear narrative of treatment progression and medical necessity. This represents a composite of successful strategies, not a guarantee of outcomes.

Costs and Financial Assistance

Manufacturer Support

  • Incyte Patient Assistance: Pemazyre Access & Support
  • Copay assistance: Available for eligible commercial patients
  • Free drug programs: For uninsured or underinsured patients

Additional Resources

  • National Organization for Rare Disorders (NORD): Financial assistance programs
  • CancerCare: Copay assistance and grants
  • Patient Advocate Foundation: Insurance appeals support

Renewal and Reauthorization

When to Reauthorize

  • Every 6-12 months depending on your plan
  • With dose changes or treatment modifications
  • If switching plans or insurance providers

Documentation for Renewal

  • Treatment response data (imaging, labs, clinical notes)
  • Continued ophthalmic monitoring results
  • Tolerability assessment and side effect management
  • Ongoing medical necessity justification

FAQ

How long does Blue Cross Blue Shield PA take in Washington? Standard requests receive decisions within 72 hours. Urgent requests are processed within 24-48 hours.

What if Pemazyre is non-formulary on my plan? You can request a formulary exception through the same PA process, emphasizing lack of therapeutic alternatives for FGFR-altered tumors.

Can I request an expedited appeal? Yes, if your health could be seriously jeopardized by delays. Washington requires expedited external reviews within 72 hours for urgent cases.

Does step therapy apply to Pemazyre? Pemazyre already requires prior therapy failure, but additional step therapy requirements may apply. Request exceptions based on contraindications or treatment urgency.

What happens if my IRO appeal is denied? While IRO decisions are typically final, you can contact the Washington Insurance Commissioner for guidance on additional options or file complaints about the process.

How much does Pemazyre cost without insurance? Specialty pharmacy pricing varies but typically ranges in the high four to five figures monthly. Manufacturer assistance programs can significantly reduce out-of-pocket costs.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters, identifies specific policy gaps, and generates evidence-backed rebuttals aligned with each payer's requirements. For complex cases like Pemazyre approvals, we help ensure all medical necessity criteria are properly documented and presented.

When facing a Pemazyre denial, having the right documentation and appeal strategy can make the difference between coverage and costly out-of-pocket payments. Counterforce Health specializes in transforming these challenges into successful outcomes through targeted, policy-specific appeals.

Mini-Checklist: Pemazyre PA Success

Before Submitting:

  • Confirm FGFR alteration with validated test
  • Document prior therapy failure
  • Complete baseline ophthalmology exam
  • Verify specialty pharmacy coordination
  • Gather all clinical documentation

After Submission:

  • Track reference numbers
  • Follow up within 72 hours
  • Prepare appeal materials if needed
  • Know your appeal deadlines (60 days)
  • Consider IRO review if internal appeals fail

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and should not be considered medical or legal advice. Always consult with your healthcare provider about treatment decisions and contact your insurance plan directly for the most current requirements and procedures. Coverage policies may change, and individual circumstances vary.

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