By Counterforce Health Team in Tagrisso (osimertinib) —

Get Tagrisso (Osimertinib) Covered by Blue Cross Blue Shield Texas: Complete Guide to Prior Authorization, Appeals & Forms

Answer Box: Getting Tagrisso Covered by BCBS Texas

Blue Cross Blue Shield of Texas requires prior authorization for Tagrisso (osimertinib) with documented EGFR mutation testing. The fastest path: 1) Have your oncologist submit PA via BCBS provider portal with EGFR lab results, 2) If denied, file internal appeal within 180 days, 3) Request expedited external review through Texas Department of Insurance for life-threatening cases. BCBS must respond to complete PA requests within 72 hours under Texas law.

Table of Contents

Start Here: Verify Your Plan & Find the Right Forms

Before requesting coverage for Tagrisso (osimertinib), confirm your specific Blue Cross Blue Shield of Texas plan type. BCBS Texas operates multiple product lines with different requirements:

  • Commercial/Employer Plans: Most common; use standard PA forms
  • Medicaid STAR/CHIP: Special forms and phone numbers
  • STAR Kids: Separate case management requirements
  • Medicare Advantage: Federal appeals rules apply

First Step: Check your member ID card or call the number on your card to confirm your plan type and whether Tagrisso requires prior authorization (it typically does).

Coverage at a Glance

Requirement What It Means Where to Find It Source
PA Required Yes, for all BCBS Texas plans BCBS TX PA Code List BCBS TX
EGFR Testing Must document specific mutation Lab report with PA submission FDA Label
Formulary Tier Specialty/Tier 4-5 typically Plan-specific drug list BCBS Portal
Step Therapy May require trying other EGFR inhibitors first PA criteria document BCBS Policy
Appeal Deadline 180 days for commercial plans Denial letter instructions TX Insurance Code

Prior Authorization Forms & Requirements

Required Documentation

Your oncologist must submit a complete prior authorization request including:

  1. EGFR Mutation Test Results: Laboratory report showing specific mutation (exon 19 deletion, L858R, or T790M)
  2. Clinical Notes: Recent oncology visit notes with diagnosis and staging
  3. Prior Treatment History: Documentation of previous therapies tried and outcomes
  4. Medical Necessity Letter: Physician's rationale for Tagrisso specifically
Clinician Corner: Medical Necessity Letter Checklist

Include these elements in your letter:Patient's specific EGFR mutation type and testing methodNSCLC staging and metastatic statusPrevious EGFR inhibitors tried (if applicable) and reason for discontinuationCitation to FDA-approved indications or NCCN guidelinesContraindications to alternative therapiesExpected treatment duration and monitoring plan

Forms by Plan Type

Commercial Plans: Use standard BCBS Texas PA forms available on provider portal

Medicaid/CHIP: Download current forms from BCBS Texas Medicaid provider section

Coverage Exception Requests: If Tagrisso is non-formulary, submit Formulary Coverage Exception Form simultaneously with PA request

Submission Portals & Upload Instructions

BCBS Texas Provider Portal: Primary method for commercial plans

  • Upload all documents as PDF files
  • Ensure lab results are clearly readable
  • Submit PA and formulary exception simultaneously if needed

Specialty Pharmacy Portal: For oral oncology drugs like Tagrisso

  • Accredo Specialty Pharmacy: Main partner for BCBS Texas
  • Prime Therapeutics: For Medicaid/CHIP plans
  • Verify your plan's designated specialty pharmacy before prescribing

Required Upload Documents

  • Completed PA form with all fields filled
  • EGFR mutation lab report (essential)
  • Recent oncology consultation notes
  • Pathology report confirming NSCLC diagnosis
  • Prior treatment summary if applicable
  • Insurance card copy
Tip: Upload all documents at initial submission. Incomplete requests are the most common cause of delays.

Fax Numbers & Mailing Addresses

Utilization Management Fax Numbers

Commercial Plans: 800-252-8815 or 800-462-3272 Medicaid STAR/CHIP: Contact 1-877-560-8055 for current fax number Appeals: 1-877-886-2593

Mailing Address for Appeals

Blue Cross Blue Shield of Texas
Appeals Department
P.O. Box 660044
Dallas, TX 75266-0044

Cover Sheet Tips: Include member ID, provider NPI, drug name (Tagrisso/osimertinib), and "URGENT - ONCOLOGY MEDICATION" for expedited processing.

Specialty Pharmacy Coordination

Tagrisso must typically be dispensed through BCBS Texas's designated specialty pharmacy network.

Specialty Pharmacy Contacts

Prime Therapeutics Specialty Pharmacy:

  • Medicaid STAR: 1-855-457-0405
  • CHIP: 1-855-457-0403
  • STAR Kids (Travis area): 1-855-457-0757
  • General Help Desk: 888-229-2812

Accredo Specialty Pharmacy: For most commercial plans

  • Contact via BCBS provider portal for setup

Transfer Process

  1. Prescription sent to designated specialty pharmacy
  2. Pharmacy initiates PA if not already approved
  3. Patient contacted for insurance verification and delivery setup
  4. First fill typically requires 3-5 business days after PA approval

Support Phone Numbers by Plan Type

Provider Relations

  • Medicaid/CHIP/STAR: 1-855-212-1615 (Mon-Fri, 8am-5pm CST)
  • General Provider Line: 800-451-0287

Case Management

  • Medicaid STAR/CHIP: 1-877-214-5630
  • STAR Kids: 1-877-214-5630
  • Commercial Plans: 800-462-3275

Prior Authorization

  • Medicaid STAR/CHIP: 1-877-560-8055
  • STAR Kids: 1-877-784-6802
  • Commercial: 800-441-9188

What to Ask: Have member ID, provider NPI, and specific questions ready. Ask for PA status, required documentation, and expected timeline.

Appeals Process: Internal & External Review

Internal Appeals

Timeline: Must file within 180 days of denial for commercial plans (60 days for Medicaid)

Submission Methods:

  • Online via member or provider portal
  • Fax to 1-877-886-2593
  • Mail to appeals address above

Required Information:

  • Copy of denial letter
  • Additional clinical documentation
  • Updated medical necessity letter
  • Any new lab results or imaging

External Review Through Texas Department of Insurance

When to Use: After internal appeal denial, or immediately for life-threatening conditions

Timeline:

  • Request within 4 months of final internal denial
  • Expedited review: 3 days for life-threatening cases
  • Standard review: 20 days

Contact: Texas Department of Insurance at 1-800-252-3439

Important: For oncology medications like Tagrisso, you can request expedited external review concurrently with internal appeals if delay would jeopardize your health.

Step Therapy Exception (Texas Law Protection)

Under Texas Insurance Code Section 1369.0546, BCBS must grant step therapy exceptions if your doctor documents that required step therapies:

  • Are contraindicated or likely to cause adverse reactions
  • Have been previously tried and failed
  • Are expected to be ineffective based on your medical history
  • Are not in your best interest clinically

Key Deadline: BCBS must respond within 72 hours to complete step therapy exception requests, or the exception is automatically granted under Texas law.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
No EGFR mutation documented Submit complete lab report Pathology report with specific mutation type
Wrong treatment setting Clarify adjuvant vs. metastatic use Updated staging and treatment plan
Step therapy not completed File step therapy exception Prior treatment failures or contraindications
Quantity limits exceeded Medical necessity for higher dose Clinical notes justifying dosing
Non-formulary drug File formulary exception Comparison to covered alternatives

Texas Regulator Assistance

Texas Department of Insurance (TDI)

  • Consumer Helpline: 1-800-252-3439
  • IRO Information: 1-866-554-4926
  • Online Complaint Filing: Available on TDI website

Office of Public Insurance Counsel (OPIC)

  • Help Line: 1-877-611-6742
  • Provides guidance on appealing denied claims

When to Contact Regulators

  • BCBS doesn't respond within required timelines
  • Improper denial of emergency supplies
  • Blocking access to external review process

Costs & Patient Assistance Programs

AstraZeneca Patient Assistance

AZ&Me Prescription Savings Program: May reduce copays for eligible patients

  • Income-based eligibility
  • Available for insured and uninsured patients
  • Apply through AstraZeneca's patient support website

Foundation Grants

  • Patient Access Network (PAN) Foundation: Lung cancer fund
  • CancerCare Co-Payment Assistance: For qualifying patients
  • Leukemia & Lymphoma Society: Patient aid program
From Our Advocates: We've seen patients successfully combine manufacturer copay assistance with foundation grants to reduce monthly costs from over $1,000 to under $100. The key is applying early in your treatment cycle, as funds are limited and distributed first-come, first-served.

FAQ: Your Top Questions Answered

Q: How long does BCBS Texas PA take for Tagrisso? A: BCBS must respond within 72 hours to complete requests under Texas law. Incomplete requests may take 2-5 business days.

Q: What if Tagrisso is non-formulary on my plan? A: File a formulary exception request simultaneously with your PA. Provide clinical justification for why covered alternatives won't work.

Q: Can I request an expedited appeal in Texas? A: Yes. For life-threatening conditions, both internal and external appeals can be expedited, with decisions required within 72 hours and 3 days respectively.

Q: Do I need to try other EGFR inhibitors first? A: This depends on your specific BCBS plan's step therapy requirements. If required, you can request a step therapy exception with clinical justification.

Q: What happens if my appeal is denied? A: You can request an Independent Review Organization (IRO) review through the Texas Department of Insurance. This is binding on BCBS if overturned.

Q: Does BCBS Texas cover Tagrisso for adjuvant treatment? A: Coverage varies by plan, but FDA approval for adjuvant EGFR-mutant NSCLC strengthens the case. Include staging documentation and treatment intent.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and plan policies to create targeted, evidence-backed appeals that align with each payer's specific requirements. For complex cases like EGFR-targeted therapies, we help identify the exact criteria needed and draft point-by-point rebuttals using the right clinical evidence and procedural requirements.

When navigating BCBS Texas requirements for Tagrisso, having the right documentation and following proper procedures significantly improves your chances of approval. Counterforce Health's systematic approach has helped many patients access critical oncology medications by ensuring appeals meet payer-specific workflows and regulatory requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and procedures change frequently. Always verify current requirements with BCBS Texas and consult with your healthcare provider about treatment decisions. For assistance with complex appeals or denials, contact the Texas Department of Insurance consumer helpline at 1-800-252-3439.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.