By Counterforce Health Team in Trikafta / Kaftrio (elexacaftor/tezacaftor/ivacaftor) —

Getting Trikafta (elexacaftor/tezacaftor/ivacaftor) Covered by Blue Cross Blue Shield of Illinois: Complete PA Guide and Appeal Process

Answer Box: Getting Trikafta Covered in Illinois

Trikafta requires prior authorization (PA) from Blue Cross Blue Shield of Illinois for cystic fibrosis patients aged ≥2 years with qualifying CFTR mutations. Submit genetic testing confirming F508del or eligible mutations, pulmonologist prescription, and CF diagnosis (ICD-10 E84.0-E84.9) via BCBSIL PA form. Approval takes 5-7 business days; if denied, internal appeals must be filed within 180 days, with external review available through Illinois Department of Insurance within 30 days of final denial.

First step today: Contact your pulmonologist to confirm genetic testing results and request the PA submission with complete documentation.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all BCBS Illinois plans BCBSIL formulary PDFs
Formulary Tier Specialty drug with PA Basic, Multi-Tier Basic, Balanced Drug Lists
Age Requirement ≥2 years old FDA label requirement
Genetic Testing F508del or qualifying CFTR mutations Lab report with specific mutation documentation
Specialist Prescription Pulmonologist required Prescription or consultation notes
Quantity Limits 84 tablets per 28-day supply Standard monthly limit
ICD-10 Code E84.0-E84.9 (CF with manifestations) Provider documentation

ICD-10 Coding for Cystic Fibrosis

Proper coding supports medical necessity and reduces denial risk. The primary code category is E84 (Cystic fibrosis) under Endocrine, nutritional, and metabolic diseases.

Billable ICD-10 Codes

  • E84.0 - Cystic fibrosis with pulmonary manifestations (most common)
  • E84.11 - Cystic fibrosis with meconium ileus
  • E84.19 - Cystic fibrosis with other intestinal manifestations
  • E84.8 - Cystic fibrosis with other manifestations
  • E84.9 - Cystic fibrosis, unspecified

Documentation Requirements

Your provider should document specific manifestations to support the appropriate subcode:

  • Pulmonary: Chronic lung inflammation, viscous secretions, recurrent infections
  • Intestinal: Pancreatic insufficiency, digestive issues, nutritional deficiencies
  • Other: CF-related diabetes (code also E08.9), liver disease
Note: While genetic mutations like F508del are crucial for Trikafta eligibility, ICD-10 codes don't capture genotype. Include mutation details in clinical notes and genetic testing reports.

NDC Codes and Pharmacy Benefit Billing

Trikafta is billed exclusively under the pharmacy benefit (not medical benefit) using NDC codes. There is no HCPCS J-code for this oral medication.

NDC Codes for Billing

  • Tablets (56-count): 51167-350-56
  • Tablets (84-count): 51167-350-84
  • Granules: 51167-115-01, 51167-115-04

Pharmacy vs. Medical Benefit

Aspect Pharmacy Benefit (Trikafta) Medical Benefit
Coverage Part D, Medicaid Rx, commercial PBMs Not applicable
Dispensing Retail/specialty pharmacy N/A
OOP Cap $2,000 (2025 Medicare Part D) N/A
PA Requirements Genetic test, CF diagnosis, specialist Rx N/A

Step-by-Step: Fastest Path to Approval

1. Confirm Genetic Testing Results

Who: Patient/family
Document needed: Lab report showing F508del or qualifying CFTR mutation
Timeline: If not done, allow 2-3 weeks for testing
Source: FDA-approved mutations list

2. Schedule Pulmonologist Visit

Who: Patient
Document needed: Specialist prescription or consultation note
Timeline: 1-2 weeks for appointment
Submit via: Provider's office handles PA submission

3. Gather Required Documentation

Who: Provider's office
Documents needed:

  • CF diagnosis with ICD-10 code (E84.0-E84.9)
  • Genetic testing results
  • Current lung function tests (FEV1, if available)
  • Prior therapy failures (if applicable)

4. Submit Prior Authorization

Who: Provider
Submit via: BCBSIL PA form (fax number on form)
Timeline: 5-7 business days for decision
Track status: MyPrime.com or Blue Access for Members

5. Follow Up on Decision

Who: Patient/provider
Timeline: Contact after 7 business days if no response
Next step: If denied, proceed to appeals process

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
Missing genetic testing Submit lab report with specific CFTR mutations Genetic testing results showing F508del or qualifying mutation
Non-specialist prescription Obtain pulmonologist prescription or consultation Specialist attestation or prescription
Incomplete CF diagnosis Provide detailed diagnosis with manifestations Clinical notes with ICD-10 E84.0-E84.9
Quantity limit exceeded Adjust to standard 84 tablets/28 days Revised prescription within limits
Age requirement not met Confirm patient ≥2 years old Birth date documentation

When Counterforce Health helps patients navigate these denials, we've found that the most successful appeals include comprehensive genetic testing documentation alongside detailed clinical notes that clearly link the patient's specific CFTR mutations to their CF manifestations.

Appeals Process for BCBS Illinois

Internal Appeal (First Level)

  • Deadline: 180 days from denial notice
  • Decision timeline: 30 days (standard), 72 hours (expedited)
  • Submit via: Written appeal letter with supporting documents
  • Required: Updated medical necessity letter addressing denial reasons

External Review (Illinois Department of Insurance)

  • Deadline: 30 days from final internal denial
  • Decision timeline: 5 business days by Independent Review Organization (IRO)
  • Cost: Free to patient
  • Binding: Yes, insurer must comply if overturned
  • Contact: Illinois Department of Insurance at (877) 527-9431

Expedited Appeals

Available when:

  • Authorization expiring within 7 days
  • Risk of health deterioration
  • Disease progression documented
Tip: Illinois has a shorter external review window (30 days) compared to many states. Don't miss this deadline.

Medical Necessity Documentation

Essential Elements for PA Success

  1. CF diagnosis with specific manifestations (pulmonary, intestinal, other)
  2. Genetic confirmation of F508del or qualifying CFTR mutation
  3. Age verification (≥2 years)
  4. Specialist involvement (pulmonologist prescription/consultation)
  5. Treatment goals (improved lung function, reduced exacerbations)

Supporting Clinical Evidence

  • Recent pulmonary function tests
  • Sweat chloride test results
  • Documentation of CF complications
  • Prior therapy trials and outcomes (if applicable)

Guideline References

Cost-Saving Options

Manufacturer Support

  • Vertex Patient Services: Copay assistance and patient support programs
  • Contact: Available through prescriber or Vertex website

Insurance-Based Savings

  • 90-day supply: Lower copays through mail-order pharmacy
  • Medicare Extra Help: Eliminates deductibles and copays for eligible patients
  • State programs: Illinois may have additional assistance programs

Foundation Grants

  • Cystic Fibrosis Foundation assistance programs
  • Patient advocacy foundation grants
  • Disease-specific charitable organizations

FAQ

Q: How long does BCBS Illinois PA approval take?
A: Standard approvals take 5-7 business days. Expedited requests are processed within 24-72 hours with clinical urgency documentation.

Q: What if Trikafta is non-formulary on my plan?
A: Submit a formulary exception request with medical necessity documentation. All BCBS Illinois plans include Trikafta with PA requirements.

Q: Can I request an expedited appeal?
A: Yes, if denial creates health risks or disease progression. Provide clinical documentation supporting urgency.

Q: Do I need to try other CF medications first?
A: Step therapy requirements vary by plan. F508del patients may qualify for Trikafta without prior failures due to its superior efficacy.

Q: What happens if my appeal is denied?
A: You can request external review through Illinois Department of Insurance within 30 days. This independent review is binding on BCBS.

Q: Can my general practitioner prescribe Trikafta?
A: Most BCBS Illinois policies require pulmonologist prescription or consultation. General practitioners may need specialist involvement.

Counterforce Health specializes in turning insurance denials into successful appeals through targeted, evidence-backed strategies. Our platform helps patients, clinicians, and pharmacies navigate complex prior authorization requirements by identifying specific denial reasons and crafting point-by-point rebuttals aligned with each payer's own criteria. Learn more about our services.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements may change. Always verify current requirements with Blue Cross Blue Shield of Illinois and consult healthcare providers for medical decisions. For personalized assistance with insurance appeals, contact the Illinois Department of Insurance or qualified advocacy services.

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