By Counterforce Health Team in Xembify (immune globulin, SC) —

Get Xembify (Immune Globulin, SC) Covered by Blue Cross Blue Shield Virginia: Forms, Appeals & Approval Guide 2024

Answer Box: Getting Xembify Covered in Virginia

Xembify requires prior authorization from Blue Cross Blue Shield Virginia before coverage begins. The fastest path to approval: 1) Have your doctor submit a PA request through the Availity Essentials portal with complete PID diagnosis documentation, 2) Include lab results showing low immunoglobulin levels and infection history, and 3) Document any failed or contraindicated IVIG treatments. If denied, you have 180 days for internal appeals plus Virginia's external review process through the State Corporation Commission. Start today by calling your doctor's office to initiate the PA request.

Table of Contents

Verify Your Plan & Find Resources

Before starting your Xembify approval process, confirm you have Blue Cross Blue Shield coverage in Virginia. The state has multiple Blue plans:

  • Anthem Blue Cross Blue Shield Virginia (serves most of the state except Fairfax City, Vienna, and areas east of State Route 123)
  • CareFirst BlueCross BlueShield (serves Northern Virginia)
Tip: Check your insurance card for the specific plan name and member services number. Each Blue plan has slightly different forms and processes.

Your plan's drug formulary determines Xembify's coverage tier and requirements. Most Virginia Blue Cross Blue Shield plans classify Xembify as a specialty drug requiring prior authorization.

Required Forms & Documentation

Prior Authorization Requirements

Xembify requires prior authorization for all Blue Cross Blue Shield Virginia plans as of 2024, following updated specialty pharmacy policies effective June 1, 2024. Your healthcare provider must submit:

Clinical Documentation Checklist:

  • Primary immunodeficiency diagnosis with ICD-10 codes
  • Laboratory results showing low immunoglobulin levels (IgG, IgA, or IgM)
  • Documentation of recurrent infections or immune dysfunction
  • Prior treatment history (IVIG trials, failures, or contraindications)
  • Dosing calculations based on patient weight
  • Treatment goals and monitoring plan

Required Forms:

  • Prior authorization request form (available through provider portal)
  • Medical necessity letter from prescribing physician
  • Patient demographics and insurance verification
  • Clinical notes supporting PID diagnosis
Note: Claims will be denied if prior authorization isn't obtained before administering Xembify.

Medical Necessity Letter Template

Your doctor's medical necessity letter should include:

  1. Patient's diagnosis with specific ICD-10 codes for primary immunodeficiency
  2. Clinical presentation including infection history and immune testing results
  3. Previous treatments tried and their outcomes or contraindications
  4. Why Xembify is appropriate (subcutaneous vs. intravenous preference, home administration benefits)
  5. Dosing rationale based on patient weight and clinical guidelines
  6. References to FDA labeling and immunodeficiency treatment guidelines

Submission Portals & Methods

Electronic Submission

Availity Essentials Portal is the primary submission method for Anthem Blue Cross Blue Shield Virginia:

  • Access at anthem.com/provider
  • Allows real-time status tracking
  • Upload supporting documents directly
  • Faster processing than fax/mail submissions

Provider Account Requirements:

  • Active Anthem provider agreement
  • Availity registration and login credentials
  • Electronic attachments capability for labs and clinical notes

Alternative Submission Methods

If electronic submission isn't available:

  • Fax: Contact your specific Blue plan for current PA fax numbers (verify with source linked below)
  • Mail: Submit to address provided in provider manual
  • Phone: For urgent cases, call provider services for expedited review
Important: Always verify current submission methods through your provider portal, as contact information changes periodically.

Fax Numbers & Mailing Addresses

Current contact information varies by specific Blue Cross Blue Shield Virginia plan. Always verify these numbers through your provider portal or by calling:

Anthem Blue Cross Blue Shield Virginia:

  • Provider Services: 1-800-331-1476 (8 a.m. to 5 p.m. ET)
  • Prior Authorization Inquiries: (800) 677-6669

CareFirst BlueCross BlueShield (Northern Virginia):

  • Contact member services number on your insurance card for current PA submission details
Cover Sheet Tips: Include patient name, insurance ID, provider NPI, urgency level, and page count on all fax submissions.

Specialty Pharmacy Network

Blue Cross Blue Shield Virginia maintains a Designated Medical Specialty Pharmacy Drug List requiring certain drugs to be obtained through network pharmacies. Xembify may be subject to these requirements.

Network Pharmacy Steps:

  1. Verify if Xembify requires designated specialty pharmacy dispensing
  2. Confirm your preferred pharmacy is in-network
  3. Coordinate with pharmacy for prior authorization support
  4. Arrange for home delivery or clinic administration as appropriate

Xembify Administration Options:

  • Home self-administration with training
  • Infusion center or clinic administration
  • Specialty pharmacy coordination for supplies and training

Support Contact Numbers

Patient Support:

  • Member Services: Number on your insurance card
  • Prior Authorization Status: Available through member portal

Provider Support:

  • Anthem Provider Services: 1-800-331-1476
  • Clinical Review Team: (800) 677-6669
  • Availity Technical Support: Available through provider portal

Xembify Manufacturer Support:

  • Grifols Patient Support: Available through Xembify.com
  • Coverage and reimbursement assistance
  • Patient assistance programs

Virginia Appeals & External Review

Internal Appeals Process

If your initial PA request is denied, you have 180 days to file an internal appeal with Blue Cross Blue Shield Virginia.

Appeal Submission Requirements:

  • Written appeal letter explaining medical necessity
  • Additional clinical documentation
  • Updated treatment rationale
  • Peer-to-peer review request if needed

Virginia External Review

After exhausting internal appeals, Virginia's State Corporation Commission Bureau of Insurance provides external review:

Timeline: 120 days from final internal denial to submit Form 216-A Process: Independent medical review by board-certified physicians Cost: Free to consumers

Required Forms:

Submission Methods:

Expedited Review: Available for urgent medical situations with provider certification (Form 216-C)

Virginia Advantage: The state provides free external review and has special provisions for expedited cancer treatment appeals without exhausting internal appeals first.

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
Missing PID diagnosis Submit complete immunology workup IgG/IgA/IgM levels, infection history, specialist evaluation
No prior IVIG trial Document IVIG failure or contraindication Treatment records, adverse reactions, medical contraindications
Exceeding dose limits Provide weight-based dosing rationale Patient weight, dosing calculations, clinical guidelines reference
Non-formulary status Request formulary exception Medical necessity letter, alternative drug failures
Step therapy required Document preferred agent medical necessity Clinical reasons for Xembify over alternatives

Costs & Patient Assistance

Xembify Retail Costs (cash prices):

  • 5 mL/1 g vial: ~$196
  • 50 mL/10 g vial: ~$1,889

Patient Assistance Options:

  • Grifols patient assistance programs
  • Copay assistance cards (for eligible commercial insurance)
  • State pharmaceutical assistance programs in Virginia
  • Foundation grants for immunodeficiency patients

Coverage Optimization:

  • Work with Counterforce Health to turn denials into targeted appeals with evidence-backed documentation
  • Utilize specialty pharmacy support for coverage navigation
  • Consider patient assistance while appeals are pending

From our advocates: We've seen patients succeed by submitting comprehensive appeals that directly address the specific denial reasons. One approach that works well is having the immunologist write a detailed letter explaining why subcutaneous administration is medically preferable to IV therapy for the individual patient's lifestyle and clinical needs. This personalized approach often resonates with reviewers.

FAQ

How long does Blue Cross Blue Shield Virginia PA take? Standard prior authorization decisions are typically made within 5-15 business days. Urgent requests may be expedited to 72 hours with proper clinical justification.

What if Xembify is non-formulary on my plan? Request a formulary exception by demonstrating medical necessity and documenting failures or contraindications to formulary alternatives.

Can I request an expedited appeal in Virginia? Yes, if your doctor certifies that treatment delay would seriously jeopardize your health. Use Form 216-C for expedited external review.

Does step therapy apply if I've tried IVIG outside Virginia? Previous treatment records from any state should count toward step therapy requirements. Submit comprehensive documentation of all prior therapies.

What happens if my appeal is denied? After internal appeals, you can request external review through Virginia's State Corporation Commission. The independent review decision is binding on the insurer.

How do I find my plan's current formulary? Check your Blue Cross Blue Shield Virginia member portal or contact member services for the most current drug list and coverage tiers.

Counterforce Health specializes in helping patients navigate complex insurance appeals for specialty medications like Xembify. Their platform transforms denial letters into targeted, evidence-backed appeals by analyzing payer policies and crafting point-by-point rebuttals with the right clinical documentation and regulatory citations. For patients facing repeated denials or complex coverage situations, Counterforce Health provides the expertise to turn insurance obstacles into approval pathways.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with your specific Blue Cross Blue Shield Virginia plan and consult with your healthcare provider for medical decisions. For personalized assistance with insurance appeals, contact the Virginia State Corporation Commission at 1-877-310-6560.

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