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

How to Get Acthar Gel Covered by Blue Cross Blue Shield in Ohio: Prior Authorization Forms, Appeals Process, and Success Strategies

Quick Answer: Getting Acthar Gel Covered in Ohio

Getting Acthar Gel (repository corticotropin injection) approved by Blue Cross Blue Shield in Ohio requires prior authorization for all patients. The fastest path: verify your BCBS plan covers the medication, gather documentation of failed corticosteroid trials, and submit through your provider's portal with complete clinical notes. Most approvals take 72 hours for urgent cases, 7-14 days for standard requests. If denied, Ohio patients have strong appeal rights including external review through the Ohio Department of Insurance. First step today: Call your BCBS member services to confirm your specific plan's formulary status and PA requirements.

Table of Contents

What This Guide Covers

This guide helps Ohio patients and their healthcare providers navigate Blue Cross Blue Shield's prior authorization process for Acthar Gel (repository corticotropin injection). Whether you're dealing with infantile spasms, multiple sclerosis exacerbations, or other FDA-approved conditions, you'll learn exactly what documentation BCBS requires, how to avoid common pitfalls, and what to do if you're initially denied.

Acthar Gel is a high-cost specialty medication requiring prior authorization from virtually all insurance plans. Research shows that over 80% of prior authorization appeals succeed, but only one in ten denials are actually appealed. This guide aims to change that by giving you the tools to get approved on the first try—or successfully appeal if necessary.

Before You Start: Plan Verification

Confirm Your Blue Cross Blue Shield Plan Type

Ohio has several BCBS options, and requirements vary:

  • Anthem Blue Cross Blue Shield Ohio (individual and employer plans)
  • Medical Mutual of Ohio (Blue Cross Blue Shield affiliate)
  • Federal Employee Program (FEP) Blue Cross Blue Shield
  • Medicare Advantage Blue Cross Blue Shield plans

Call the member services number on your insurance card to confirm which specific BCBS plan you have and whether it's fully insured (subject to Ohio regulations) or self-funded (governed by federal ERISA law).

Check Pharmacy vs. Medical Benefit

Acthar Gel may be covered under your pharmacy benefit or medical benefit depending on where it's administered. Most plans cover it under the medical benefit when given in a clinic, but self-administered injections often fall under pharmacy benefits with different prior authorization requirements.

Tip: Ask your provider's office to verify benefit coverage before starting the PA process. This prevents delays and ensures you're using the correct forms.

Coverage at a Glance

Requirement Details Where to Find It
Prior Authorization Required for all BCBS plans Member handbook or provider portal
Primary Indications Infantile spasms, MS exacerbations FDA label
Step Therapy Must try corticosteroids first Plan formulary or PA criteria
Quantity Limits Typically 4 vials per 30 days Plan-specific policy
Age Restrictions Under 2 years for infantile spasms Clinical policy documents
Appeals Deadline 180 days from denial Ohio Department of Insurance

Step-by-Step: Fastest Path to Approval

1. Verify In-Network Status (Patient/Provider)

Confirm your prescribing physician is in-network with your BCBS plan. Out-of-network prescribers face additional hurdles and may require referrals. Timeline: 5-10 minutes Source: BCBS provider directory online

2. Obtain Prior Authorization Form (Provider)

Download the current PA form from your BCBS plan's provider portal. Forms are updated regularly, so don't use old versions. Timeline: Same day Submit via: Provider portal or fax (verify current fax number with plan)

3. Document Step Therapy Compliance (Provider)

Gather records showing trials and failures of:

  • For infantile spasms: Oral prednisolone or vigabatrin
  • For MS exacerbations: High-dose IV methylprednisolone or oral prednisone Include specific dates, doses, duration, and outcomes (lack of efficacy, intolerance, contraindications). Timeline: 1-2 business days to compile records

4. Submit Complete Request Packet (Provider)

Include: PA form, clinical notes, prior therapy documentation, specialist consultation notes, relevant labs/imaging, and treatment plan. Timeline: 72 hours for urgent requests, 7-14 days standard Expected outcome: 60-70% approval rate on first submission with complete documentation

5. Follow Up Proactively (Patient/Provider)

Call within 5 business days if no decision. Document reference numbers and representative names. Timeline: Daily calls after initial deadline passes

6. Request Peer-to-Peer if Needed (Provider)

If additional information is requested, offer to schedule a peer-to-peer review with the medical director. Timeline: Usually scheduled within 48-72 hours

7. File Appeal if Denied (Patient/Provider)

Ohio patients have 180 days to file internal appeals, followed by external review through the Ohio Department of Insurance. Timeline: 30 days for internal appeal decision, 30 days for external review

What You Need to Gather

Clinical Documentation Checklist

  • Current diagnosis with ICD-10 codes
  • Specialist consultation notes (neurologist for MS/infantile spasms)
  • Complete medication history with specific dates and outcomes
  • Laboratory results supporting diagnosis
  • Treatment goals and monitoring plan
  • Contraindications to alternative therapies (if applicable)

Prior Therapy Documentation

  • Pharmacy records showing filled prescriptions
  • Clinical notes documenting response to previous treatments
  • Hospital records for IV steroid treatments
  • Documentation of adverse effects or intolerances
  • Specialist letters explaining why alternatives aren't suitable
Clinician Corner: Medical necessity letters should follow this structure: 1) Patient diagnosis and severity, 2) Prior treatments tried with specific dates/doses/outcomes, 3) Clinical rationale for Acthar Gel specifically, 4) References to FDA labeling or specialty guidelines, 5) Proposed dosing and monitoring plan. Include objective measures like seizure frequency or EDSS scores where applicable.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Evidence
"Step therapy not completed" Document corticosteroid trials Pharmacy records showing dates, doses, and clinical notes showing outcomes
"Not medically necessary" Provide specialist support Neurologist letter explaining why Acthar is specifically needed vs. alternatives
"Experimental/investigational" Confirm FDA-approved indication Copy of FDA label highlighting approved indication
"Quantity exceeds limits" Justify dosing Literature supporting higher doses or specialist letter explaining medical necessity
"Missing clinical information" Submit complete records All requested documentation with clear organization

Appeals Process in Ohio

Internal Appeals (First Level)

Deadline: 180 days from denial notice
Timeline: 30 days for standard review, 72 hours for urgent appeals
How to file: Written request to BCBS with original denial letter and additional supporting documentation
Success rate: Approximately 20-30% of internal appeals succeed

External Review (Independent Review)

When available: After exhausting internal appeals or if BCBS doesn't respond within required timeframes
Deadline: 180 days from final internal denial
Process: File request with your BCBS plan, which forwards to Ohio Department of Insurance
Contact: Ohio Department of Insurance Consumer Services: 1-800-686-1526
Timeline: 30 days standard, 72 hours expedited
Success rate: Over 40% of external reviews overturn insurer denials for specialty drugs

Note: Self-funded employer plans (ERISA plans) may use federal external review processes instead of Ohio's state process. Your plan administrator can clarify which process applies.

At Counterforce Health, we help patients and providers navigate complex prior authorization and appeals processes by turning insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to create point-by-point rebuttals aligned with each payer's specific requirements.

Ohio Department of Insurance Resources

  • Consumer Hotline: 1-800-686-1526
  • External Review Information: Available on ODI website
  • Complaint Filing: Online portal for insurance disputes
  • OSHIIP Program: Medicare-specific assistance for seniors

Scripts for Calling Your Insurance

Initial PA Status Check

"Hi, I'm calling to check the status of a prior authorization request for Acthar Gel submitted on [date]. The patient is [name], member ID [number]. Can you tell me if it's been received and what the expected timeline is? Also, is there any additional information needed?"

Appeal Status Follow-Up

"I'm following up on an internal appeal filed on [date] for denial of Acthar Gel coverage. Reference number is [if available]. The 30-day review period expires on [date]. Can you provide a status update and confirm when the decision will be issued?"

Peer-to-Peer Request

"The prior authorization was denied, and we'd like to request a peer-to-peer review with your medical director. The prescribing physician is available [days/times]. What's the process to schedule this, and what information should be prepared?"

Renewal and Re-Authorization

Most Acthar Gel approvals are time-limited and require renewal:

Infantile Spasms

  • Initial approval: 4 weeks to 3 months
  • Renewal criteria: Documented seizure reduction, EEG improvements
  • Documentation needed: Treatment response notes, updated specialist evaluation

Multiple Sclerosis Exacerbations

  • Initial approval: 2-3 weeks per episode
  • Renewal: New episodes require separate authorization
  • Documentation needed: Evidence of new exacerbation, EDSS scores if available

Renewal Timeline

Submit renewal requests 2-3 weeks before current authorization expires. Include:

  • Current clinical status and response to treatment
  • Any changes in condition or other medications
  • Updated specialist recommendations
  • Objective measures of improvement

For ongoing treatment needs, Counterforce Health's platform can help track renewal deadlines and ensure all required documentation is included in reauthorization requests.

FAQ

How long does BCBS prior authorization take in Ohio?
Standard requests: 7-14 business days. Urgent requests: 72 hours. If BCBS doesn't respond within required timeframes, you can file for external review.

What if Acthar Gel isn't on my formulary?
You can request a formulary exception by demonstrating medical necessity and providing documentation that covered alternatives aren't suitable. The process is similar to prior authorization.

Can I get expedited approval for urgent cases?
Yes. For infantile spasms or acute MS exacerbations where delays could cause harm, request urgent review. Provide clinical documentation supporting the urgency.

Does step therapy apply if I tried steroids in another state?
Yes, documented trials from other states count toward step therapy requirements. Ensure you have complete medical records showing the treatments tried and outcomes.

What if my employer plan is self-funded?
Self-funded plans follow federal ERISA law rather than Ohio insurance regulations. Appeals may go through federal external review rather than the Ohio Department of Insurance process.

How much does Acthar Gel cost without insurance?
A single 5-mL vial typically costs tens of thousands of dollars. The manufacturer offers patient assistance programs—contact Acthar Patient Support for eligibility information.

Can I appeal to the Ohio Department of Insurance if my first appeal fails?
Yes, Ohio residents can request external review after exhausting internal appeals. The process is free and provides an independent medical expert review of your case.

What happens if external review approves my case?
The decision is binding on your insurance company—they must provide coverage as ordered by the independent review organization.

From Our Advocates: "We've seen cases where patients gave up after an initial denial, not realizing how strong their appeal case was. One family dealing with infantile spasms had their Acthar Gel approved on external review after documenting that standard seizure medications caused severe side effects. The key was organizing all the medical records chronologically and getting a detailed letter from their pediatric neurologist explaining why Acthar was the only viable option. Remember, external review gives you a fresh set of eyes from independent medical experts."

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by specific Blue Cross Blue Shield plan and individual circumstances. Always consult with your healthcare provider and insurance plan directly for the most current requirements and procedures. For additional assistance with insurance appeals in Ohio, contact the Ohio Department of Insurance Consumer Services Division at 1-800-686-1526.

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