By Counterforce Health Team in Cresemba (isavuconazole) —

How Long Does It Take to Get Cresemba (Isavuconazole) Approved by Blue Cross Blue Shield in Florida? Complete Timeline Guide

Answer Box: Getting Cresemba Approved in Florida

Blue Cross Blue Shield of Florida typically requires prior authorization for Cresemba (isavuconazole) with 2-3 business days for electronic submissions and up to 14 calendar days for fax requests. The fastest path: have your infectious disease specialist submit complete documentation via electronic PA portal (CoverMyMeds or Availity) including diagnosis confirmation, voriconazole contraindication/failure records, and medical necessity letter. Start by calling Florida Blue member services to verify PA requirements and obtain current forms.

Table of Contents

  1. What Affects Approval Timeline
  2. Pre-Submission Preparation (0-2 Days)
  3. Submission to Initial Review (1-5 Days)
  4. Additional Information Requests (1-7 Days)
  5. Decision Window & Reading Results
  6. If Denied: Appeal Timeline
  7. Renewal Cycles & Reauthorization
  8. Timeline Visual Summary
  9. Time-Saving Tips
  10. Common Denial Reasons & Fixes
  11. FAQ

What Affects Approval Timeline

Several factors determine how quickly Florida Blue processes your Cresemba prior authorization:

Benefit Type: Specialty medications like Cresemba are typically managed under pharmacy benefits with Prime Therapeutics as the PBM. This standardizes review processes but requires specific clinical documentation.

Complexity of Criteria: Invasive fungal infections require detailed diagnostic evidence. Florida Blue expects confirmation of invasive aspergillosis or mucormycosis with supporting microbiology, imaging, or pathology results.

Documentation Completeness: Electronic submissions with all required attachments process fastest. Missing information triggers "pending more info" status, extending timelines significantly.

Prescriber Specialty: Infectious disease specialist involvement often accelerates approval since reviewers expect specialist management for invasive fungal diseases.

Note: Florida Blue has implemented AI-supported review systems that can auto-approve straightforward cases within seconds, while complex cases receive human clinical review within standard timeframes.

Pre-Submission Preparation (0-2 Days)

Essential Documentation Checklist

Before submitting your PA request, gather these required materials:

Clinical Evidence:

  • Confirmed diagnosis with ICD-10 codes (B44.0-B44.9 for aspergillosis; B46.0-B46.9 for mucormycosis)
  • Laboratory results: fungal cultures, galactomannan, beta-D-glucan
  • Imaging reports (CT chest/sinuses) showing invasive disease
  • Pathology reports if tissue biopsy performed

Treatment History:

  • Complete record of prior antifungal therapies
  • Dates, doses, and outcomes for voriconazole trials
  • Documentation of adverse effects or contraindications
  • Specialist consultation notes

Prescriber Information:

  • Infectious disease specialist involvement (preferred)
  • Medical necessity letter explaining Cresemba selection
  • Planned treatment duration and monitoring

Verification Steps

  1. Confirm PA Requirement: Call Florida Blue member services using the number on your ID card
  2. Check Formulary Status: Verify Cresemba's tier and any step therapy requirements via MyPrime portal
  3. Obtain Current Forms: Download latest PA forms from Florida Blue provider portal

Submission to Initial Review (1-5 Days)

Florida Blue PA Timeline Standards

Based on Florida Blue's published guidelines and third-party PA assistance services:

Electronic Submissions (CoverMyMeds/Availity):

  • 2-3 business days for most complete requests
  • AI screening occurs immediately
  • Human review for complex cases within standard timeframe

Fax Submissions:

  • 10 calendar days for complete submissions
  • Up to 15 working days if information is missing
  • Higher risk of processing delays

State Requirements

Florida follows federal standards for PA processing:

  • Standard decisions: Within timeframes specified in plan documents
  • Expedited decisions: 72 hours when delay could seriously jeopardize life or health
  • Member notification: Written decision letter mailed and often available via portal
Tip: For active invasive fungal infections, request expedited review and include clinical urgency statement from your ID specialist.

Additional Information Requests (1-7 Days)

If Florida Blue requests additional information, respond promptly to avoid extended delays:

Common Information Requests:

  • Additional specialist consultation notes
  • Updated laboratory or imaging results
  • Clarification on voriconazole contraindication
  • Detailed drug interaction assessment

Response Strategy:

  • Submit via same channel as original request
  • Include reference number from initial submission
  • Attach comprehensive response addressing all questions
  • Follow up within 48 hours if no acknowledgment received

Hold Queue Impact: Incomplete responses can extend total timeline to 15+ days, especially for fax submissions.

Decision Window & Reading Results

Approval Letter Components

Your approval notification will include:

  • Authorization dates (start and end dates)
  • Approved quantity and refill limitations
  • Specialty pharmacy requirements
  • Prior authorization number for pharmacy claims

Coverage Details

Approved Cresemba typically includes:

  • Loading dose regimen: 372 mg every 8 hours × 6 doses
  • Maintenance dosing: 372 mg daily
  • IV to oral conversion without re-loading
  • Duration: Often 3-6 months initially, requiring reauthorization

If Denied: Appeal Timeline

Florida provides robust appeal rights for PA denials:

Internal Appeal Process

Timeline to File: 180 days from denial notice Plan Decision Timeline:

  • Standard appeals: Within timeframes in plan documents (typically 30 days)
  • Expedited appeals: 72 hours for urgent cases

Required Documentation:

  • Original denial letter
  • Updated clinical information
  • Strengthened medical necessity letter
  • Specialist support letter

External Review Option

If internal appeal fails: Timeline to Request: 4 months after final internal denial Process: Contact Florida Department of Financial Services Decision Timeline: Varies by case complexity Cost: No charge to consumer

Important: External review decisions are binding on the insurer under Florida law.

Renewal Cycles & Reauthorization

Typical Authorization Periods

Initial Authorization: 3-6 months for acute treatment Renewal Cycles: Every 6-12 months for extended therapy Required for Renewal:

  • Updated clinical status
  • Evidence of continued medical necessity
  • Response to treatment documentation
  • Ongoing specialist involvement

Renewal Timeline Strategy

Start renewal process 2-4 weeks before expiration:

  1. Review current authorization end date
  2. Gather updated clinical documentation
  3. Submit renewal request via same channel
  4. Include progress notes and any new imaging/lab results

Timeline Visual Summary

Phase Electronic PA Fax PA Expedited
Pre-submission prep 1-2 days 1-2 days 1 day
Initial review 2-3 business days 10 calendar days 24-72 hours
Info requests (if needed) 1-3 days 3-7 days Same day
Decision notification Same day 1-2 days Immediate
Total typical timeline 3-8 days 14-21 days 1-3 days

Time-Saving Tips

Portal Optimization

  • Use electronic submission whenever possible
  • Bundle all documents in initial submission
  • Include reference numbers from previous authorizations
  • Upload high-quality scans of all supporting documents

Clinical Documentation Best Practices

  • Lead with urgency for invasive fungal infections
  • Explicitly state contraindications to voriconazole
  • Include specialist attestation of medical necessity
  • Reference published guidelines (IDSA, ECMM) supporting Cresemba use

Direct Specialty Routing

  • Have infectious disease specialist submit PA directly
  • Include consultation notes in initial submission
  • Request peer-to-peer review if available
  • Leverage hospital discharge planning teams for complex cases

Common Denial Reasons & Fixes

Denial Reason Required Fix Documentation Needed
Insufficient diagnostic evidence Provide culture/pathology results Microbiology reports, imaging
Step therapy not completed Document voriconazole failure/contraindication Treatment history, adverse events
Non-formulary status Request formulary exception Medical necessity letter
Quantity/duration exceeded Justify extended treatment Specialist notes, clinical guidelines
Missing specialist involvement Obtain ID consultation Specialist assessment and plan

Counterforce Health helps patients and clinicians navigate complex prior authorization challenges by analyzing denial letters and crafting targeted, evidence-based appeals. Our platform identifies specific denial reasons and provides point-by-point rebuttals aligned with payer policies, significantly improving approval rates for specialty medications like Cresemba.

FAQ

How long does Blue Cross Blue Shield PA take in Florida? Electronic submissions typically process in 2-3 business days, while fax submissions can take up to 14 calendar days. Expedited reviews for urgent cases are completed within 72 hours.

What if Cresemba is non-formulary on my plan? You can request a formulary exception by documenting medical necessity and showing that covered alternatives are inappropriate. This process typically adds 3-5 days to standard PA timelines.

Can I request an expedited appeal in Florida? Yes, if delay could seriously jeopardize your life or health. Expedited appeals must be decided within 72 hours, and you can request this during initial PA or appeal processes.

Does step therapy apply if I've failed voriconazole outside Florida? Treatment history from any location is typically accepted. Provide complete documentation of prior therapy trials, outcomes, and reasons for discontinuation.

What happens if my authorization expires during treatment? Start renewal 2-4 weeks before expiration. If authorization lapses, you may need to pay out-of-pocket until renewal is approved, though some plans offer short-term continuity coverage.

Who can help if my appeal is denied? Contact the Florida Department of Financial Services Insurance Consumer Helpline at 1-877-693-5236 for assistance with external review requests and insurance complaints.

For complex cases requiring targeted appeal strategies, Counterforce Health provides specialized support in overturning prior authorization denials through evidence-based documentation and payer-specific appeal letters.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for specific coverage decisions. Prior authorization requirements and timelines may vary by plan and can change without notice.

Sources & Further Reading

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