By Counterforce Health Team in Acthar Gel (repository corticotropin injection) —

Getting Acthar Gel Approved by Blue Cross Blue Shield of Texas: Prior Authorization, Appeals, and Cost-Saving Strategies

Answer Box: Getting Acthar Gel Covered by BCBS Texas

Acthar Gel requires prior authorization from Blue Cross Blue Shield of Texas, with approval based on FDA-approved indications and documented failure of corticosteroids. Your fastest path to approval: (1) Have your prescriber submit a detailed PA request through the BCBS provider portal with complete medical records showing corticosteroid failure or contraindication, (2) Ensure prescription is sent to an in-network specialty pharmacy like Accredo or CVS Specialty, and (3) If denied, file an internal appeal within 180 days, followed by an Independent Review Organization (IRO) request through the Texas Department of Insurance if needed.

Table of Contents

  1. Coverage Basics: Is Acthar Gel Covered?
  2. The Prior Authorization Process
  3. Timing: How Long Does Approval Take?
  4. Medical Necessity Criteria
  5. Understanding Your Costs
  6. When Coverage Is Denied: Appeals Process
  7. Renewal Requirements
  8. Specialty Pharmacy Requirements
  9. Troubleshooting Common Issues
  10. Frequently Asked Questions

Coverage Basics: Is Acthar Gel Covered?

Blue Cross Blue Shield of Texas (BCBSTX) covers Acthar Gel (repository corticotropin injection) on both their Performance Drug List and Balanced Drug List, but with strict requirements:

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required Provider must get approval before dispensing BCBSTX PA Codes
Specialty Tier Placement High coinsurance (typically 20-50%) Your plan's Summary of Benefits
Step Therapy Must try corticosteroids first Clinical Criteria
Specialty Pharmacy Only Must use contracted specialty pharmacy Member Services: number on your ID card
FDA-Approved Indications Limited to labeled uses FDA prescribing information

The Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Provider Initiates PA (Day 1)
    • Only your prescribing physician can submit the PA request
    • Submit through BCBSTX provider portal or call member services
    • Required: Complete medical records, diagnosis codes, treatment history
  2. Gather Required Documentation (Days 1-2)
    • Confirmed diagnosis with ICD-10 codes
    • Records of previous corticosteroid trials and outcomes
    • Clinical notes supporting medical necessity
    • Current medication list and relevant lab results
  3. Submit Complete Request (Day 2-3)
    • Include detailed rationale for Acthar Gel over alternatives
    • Specify monitoring plan and treatment goals
    • Attach prescriber attestation if required
  4. BCBSTX Reviews (Days 4-30)
    • Standard review: up to 30 days for pre-service requests
    • Expedited review: 72 hours if urgent health risk documented
  5. Receive Decision (Day 30 or sooner)
    • Approval: prescription can be filled at specialty pharmacy
    • Denial: appeal rights and reasons provided
  6. Fill at Specialty Pharmacy (Upon approval)
    • Transfer prescription to contracted specialty pharmacy
    • Coordinate delivery and injection training
  7. Monitor and Document (Ongoing)
    • Track clinical response for renewal requirements
    • Maintain detailed treatment records
Tip: Incomplete documentation is the most common reason for delays. Ensure all prior therapies are thoroughly documented with dates, doses, and reasons for discontinuation.

Timing: How Long Does Approval Take?

Standard Timeline:

  • Pre-service requests: Up to 30 days
  • Post-service requests: Up to 60 days
  • Expedited/urgent requests: 72 hours

When to Request Expedited Review: Your doctor can request expedited processing if waiting for standard review would:

  • Seriously jeopardize your health
  • Jeopardize your ability to regain maximum function
  • Subject you to severe pain that cannot be adequately managed

The physician must provide clinical justification for urgency in the PA request.

Medical Necessity Criteria

Clinician Corner: Medical Necessity Requirements

BCBSTX typically requires documentation of:

✓ FDA-approved indication (infantile spasms, MS exacerbations, specific rheumatologic conditions) ✓ Step therapy completion - documented trial and failure of corticosteroids ✓ Clinical contraindications to first-line therapies (if applicable) ✓ Age-appropriate dosing and administration plan ✓ Monitoring protocol for efficacy and safety

Common FDA-Approved Indications:

  • Infantile spasms (West syndrome) in patients under 2 years
  • Acute exacerbations of multiple sclerosis
  • Severe exacerbations of systemic lupus erythematosus
  • Symptomatic sarcoidosis
  • Certain nephrotic syndromes

Required Clinical Documentation:

  • Complete diagnostic workup supporting the indication
  • Detailed history of previous treatments and outcomes
  • Current clinical status and treatment goals
  • Plan for monitoring response and managing side effects

Understanding Your Costs

Acthar Gel is typically placed on the highest specialty tier, resulting in significant out-of-pocket costs even with insurance coverage.

Potential Cost-Saving Options:

Acthar Gel Commercial Co-Pay Program

  • Eligible patients may pay as little as $0 out-of-pocket
  • Maximum benefit: $15,000 per calendar year
  • Available for commercial insurance plans
  • Contact: 1-888-435-2284

Acthar Patient Assistance Program

  • Free medication for qualifying uninsured or underinsured patients
  • Financial need-based eligibility
  • Includes case management support

Specialty Pharmacy Support

  • Many specialty pharmacies offer financial counseling
  • Help identifying additional assistance programs
  • Coordination with manufacturer support programs

For comprehensive support navigating insurance approvals and appeals, Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and drafting point-by-point rebuttals aligned to each plan's specific criteria.

When Coverage Is Denied: Appeals Process

Texas Appeals Process for BCBSTX Denials

Internal Appeal (First Level)

Deadline: 180 days from denial notice How to file:

  • Call customer service number on your BCBSTX ID card
  • Submit written appeal with supporting documentation
  • Provider can submit electronically through portal

Required Documentation:

  • Original denial letter
  • Additional clinical evidence supporting medical necessity
  • Prescriber's letter of medical necessity
  • Literature supporting off-label use (if applicable)

Decision Timeline:

  • Standard: 30 days (pre-service), 60 days (post-service)
  • Expedited: 72 hours (with clinical justification)

External Review (IRO)

If your internal appeal is denied, you can request an Independent Review Organization (IRO) review through the Texas Department of Insurance.

Eligibility: Available for state-regulated plans (excludes some self-funded employer plans) Deadline: 4 months from final internal denial How to request: Complete IRO form provided with denial letter

Texas Department of Insurance Contact:

  • General: 1-800-252-3439
  • IRO Information: 1-866-554-4926

IRO Decision Timeline:

  • Standard review: 20 days
  • Expedited review: 5 days
  • Decision is binding on BCBSTX

Appeals Scripts & Templates

Patient Phone Script for BCBSTX: "I'm calling to file an internal appeal for a denied prior authorization for Acthar Gel. My member ID is [ID number]. I have additional clinical documentation that supports medical necessity. Can you please start the appeal process and tell me what documents I need to submit?"

Renewal Requirements

When to Re-authorize:

  • Initial approvals typically valid for 6-12 months
  • Renewal required before current authorization expires
  • Some plans require quarterly reviews for high-cost drugs

Renewal Documentation:

  • Clinical response assessment
  • Updated treatment notes
  • Continued medical necessity justification
  • Any changes in condition or treatment goals

What Changes Trigger New PA:

  • Dose adjustments outside approved range
  • Change in indication
  • Significant gaps in therapy
  • Switch between administration routes

Specialty Pharmacy Requirements

Why Specialty Pharmacy Is Required: Acthar Gel requires special handling due to:

  • Refrigerated storage and shipping
  • Complex injection training requirements
  • High cost requiring specialized billing
  • Clinical monitoring and support needs

BCBSTX Contracted Specialty Pharmacies:

  • Accredo Specialty Pharmacy
  • CVS Specialty Pharmacy
  • Walgreens Specialty Pharmacy
  • (Verify current network with member services)
Important: Prescriptions sent to out-of-network pharmacies will be denied, making you responsible for the full cost.

What to Expect from Specialty Pharmacy:

  • Coordination with your insurance for billing
  • Refrigerated delivery to your home
  • Injection training and support
  • Clinical monitoring and follow-up
  • Refill reminders and coordination

Troubleshooting Common Issues

Common Problems and Solutions:

Issue Solution Contact
PA taking too long Request expedited review with clinical justification Provider portal or member services
Missing clinical records Work with provider to submit complete documentation Provider's office
Specialty pharmacy delays Confirm in-network status and transfer if needed Member services
Denial for "not medically necessary" File appeal with additional clinical evidence Appeals department
Portal access issues Use alternative submission methods Technical support

Frequently Asked Questions

How long does BCBSTX prior authorization take for Acthar Gel? Standard PA reviews take up to 30 days for pre-service requests. Expedited reviews (with clinical justification of urgency) are completed within 72 hours.

What if Acthar Gel is non-formulary on my plan? You can request a formulary exception through the same PA process. Your provider must demonstrate medical necessity and why formulary alternatives are inappropriate.

Can I request an expedited appeal in Texas? Yes, if your physician documents that delays would seriously jeopardize your health. Both internal appeals and IRO reviews offer expedited timelines.

Does step therapy apply if I failed corticosteroids in another state? Yes, documented treatment failures from other states should be accepted. Ensure complete medical records are transferred and included in your PA request.

What happens if my employer plan is self-funded? Self-funded ERISA plans may not be subject to Texas IRO review. These plans typically follow federal appeal processes with external review through independent organizations.

How do I find BCBSTX's current specialty pharmacy network? Call the member services number on your ID card for the most current list of contracted specialty pharmacies for your specific plan.

Can I continue my current dose during an appeal? You may request continuity of care coverage if you file your appeal within 10 days of receiving the denial notice and are currently stable on the medication.

What if I can't afford my copay even with insurance? Contact Acthar Patient Support at 1-888-435-2284 to discuss the Commercial Co-Pay Program and other financial assistance options.

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about your specific medical condition and treatment options. Insurance coverage and requirements may vary by plan and change over time.

For additional help with insurance appeals and coverage issues in Texas, contact the Texas Department of Insurance at 1-800-252-3439 or visit their consumer complaint page.

When facing complex insurance denials, Counterforce Health specializes in helping patients and clinicians build stronger appeals by analyzing payer-specific criteria and crafting evidence-backed responses that address the exact reasons for denial.

Sources & Further Reading

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