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

How to Get Acthar Gel Covered by Blue Cross Blue Shield Michigan: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Acthar Gel Covered by Blue Cross Blue Shield Michigan

Quick Answer: Blue Cross Blue Shield of Michigan (BCBSM) requires strict prior authorization for Acthar Gel and primarily covers it only for infantile spasms in children under 2 years. For other conditions, you'll need comprehensive documentation of corticosteroid failure or contraindications. Submit PA requests via Availity Essentials or the Acthar MARF form (fax 1-877-325-5979). If denied, use Michigan's 127-day external review process through DIFS.

Start today: Contact your prescriber to gather documentation of all prior steroid trials and their outcomes.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Medical Necessity Documentation
  4. Common Denial Reasons & Solutions
  5. Appeals Process in Michigan
  6. Cost-Saving Programs
  7. When to Escalate
  8. FAQ

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all uses BCBSM PA Guidelines
Covered Indication Infantile spasms (West syndrome) in children <2 years BCBSM Acthar Policy
Quantity Limit 4 vials per 30 days maximum BCBSM Medical Policy
Duration Limit 60 days initial approval, no renewals BCBSM MARF Form
Prescriber Specialist (neurologist for infantile spasms) PA Criteria
Step Therapy Documented failure/contraindication to corticosteroids Policy Requirements

Step-by-Step: Fastest Path to Approval

1. Confirm Your Plan Type

Who: Patient
Action: Call the member services number on your BCBSM card to verify if Acthar Gel is covered under medical or pharmacy benefits.
Timeline: 10-15 minutes
Document: Note the representative's name and confirmation number

2. Gather Treatment History

Who: Patient and prescriber's office
Action: Compile complete records of all prior corticosteroid trials, including:

  • Drug names (prednisone, methylprednisolone, etc.)
  • Exact doses and duration
  • Start/stop dates
  • Clinical outcomes
  • Adverse effects or contraindications
    Timeline: 1-2 business days

3. Have Your Specialist Complete the PA Request

Who: Prescribing physician
Action: Submit via Availity Essentials (Payer Spaces → BCBSM/BCN → Medical/Pharm Drug Benefit Prior Auth) or complete the Acthar MARF form
Timeline: Submit within 5 business days
Fax: 1-877-325-5979 (if using MARF)

4. Include Required Documentation

  • Patient demographics and BCBSM member ID
  • Diagnosis with ICD-10 code
  • Detailed treatment history
  • Medical necessity letter
  • Supporting clinical notes and lab results

5. Follow Up on Decision

Timeline: BCBSM typically responds within 14 business days for standard PA requests
Action: Call member services if no response after 15 business days

6. If Denied, File Internal Appeal

Timeline: Must appeal within 180 days of denial
Action: Submit additional documentation addressing specific denial reasons

7. External Review (If Needed)

Timeline: File with Michigan DIFS within 127 days of final internal denial
Resource: DIFS External Review Form

Medical Necessity Documentation

Clinician Corner: Essential Elements for Your Medical Necessity Letter

Your specialist's letter should include these key components:

1. Clear Diagnosis

  • Specific condition (infantile spasms/West syndrome for covered use)
  • ICD-10 code
  • Age confirmation (must be <2 years for infantile spasms)
  • Supporting diagnostic evidence (EEG findings, clinical observations)

2. Prior Treatment Documentation Create a table format like this:

Medication Dose Duration Dates Outcome Reason Stopped
Prednisone 1mg/kg/day 14 days [dates] Inadequate response Continued seizures
IV methylprednisolone 1g/day 5 days [dates] Partial response Severe hyperglycemia

3. Clinical Rationale

  • Why Acthar Gel is medically necessary
  • Why standard corticosteroids are inappropriate
  • Expected treatment goals and monitoring plan
  • Reference to FDA prescribing information

4. Supporting Evidence

  • Recent EEG reports
  • Hospital discharge summaries
  • Laboratory results showing steroid complications
  • Specialist consultation notes

Common Denial Reasons & Solutions

Denial Reason How to Address It
"Not medically necessary" Provide detailed documentation that patient meets infantile spasms criteria or has documented contraindications to steroids
"Step therapy not met" Submit comprehensive table of all prior corticosteroid trials with specific doses, dates, and outcomes
"Alternative treatments available" Document why alternatives failed or are contraindicated with objective clinical evidence
"Experimental/investigational" Reference FDA approval for patient's specific indication and cite prescribing information
"Quantity/duration exceeded" Ensure request stays within 4 vials/30 days and ≤60 days total duration per BCBSM policy

Appeals Process in Michigan

Internal Appeals with BCBSM

  • Deadline: 180 days from denial date
  • Method: Written appeal to address on denial letter
  • Timeline: 30 days for standard, 72 hours for urgent
  • Include: Original denial letter, updated medical necessity documentation, peer-to-peer request if available

Michigan DIFS External Review

Michigan offers robust external review rights under the Patient's Right to Independent Review Act:

  • Deadline: 127 days from final internal denial
  • Cost: Free to patients
  • Timeline: 60 days standard, 72 hours expedited
  • Decision: Binding on BCBSM if overturned

How to File:

  1. Complete DIFS External Review Request
  2. Include all denial letters and supporting documentation
  3. Request expedited review if delay would harm patient (requires physician letter)

Contact DIFS:

At Counterforce Health, we help patients navigate complex insurance appeals by analyzing denial letters and crafting evidence-based responses tailored to each plan's specific criteria. Our platform specializes in turning insurance denials into targeted appeals that speak directly to payer policies and medical necessity requirements.

Cost-Saving Programs

Even with insurance approval, Acthar Gel can have significant out-of-pocket costs:

Manufacturer Support:

  • Acthar Support and Access
  • Patient assistance programs for eligible patients
  • Copay assistance (income and insurance restrictions apply)

Financial Assistance:

  • Contact Mallinckrodt patient support: 1-888-756-8657
  • Verify eligibility requirements and application process

When to Escalate

Contact Michigan regulators if you experience:

  • Unreasonable delays in PA processing
  • Denial of clearly covered services
  • Problems with the appeals process

Michigan Department of Insurance and Financial Services (DIFS):

  • Consumer Hotline: 877-999-6442
  • File a Complaint
  • Address: 7109 W. Saginaw Hwy, Lansing, MI 48917
From Our Advocates: We've seen cases where BCBSM initially denied Acthar Gel for infantile spasms due to incomplete documentation, but approval was granted after the family provided a detailed timeline of prior treatments and their neurologist submitted additional EEG evidence. The key was organizing all clinical information in a clear, chronological format that directly addressed the plan's coverage criteria.

FAQ

How long does BCBSM prior authorization take for Acthar Gel? Standard PA decisions are typically made within 14 business days. Expedited requests (when delay would harm the patient) must be decided within 72 hours.

What if my child is over 2 years old but has infantile spasms? BCBSM's policy specifically requires age <2 years for infantile spasms coverage. You may need to pursue an exception through the appeals process with strong medical necessity documentation.

Can I get Acthar Gel covered for multiple sclerosis or other conditions? BCBSM's current policy primarily covers infantile spasms. Other indications typically require extensive documentation of corticosteroid failure/contraindications and may need to go through the appeals process.

Does step therapy apply if I tried steroids with a different insurance company? Yes, prior treatment history from other insurers counts toward step therapy requirements. Ensure you have complete documentation from previous providers.

What happens if DIFS external review overturns the denial? The decision is binding on BCBSM, and they must provide coverage as directed. DIFS will send written notification to both you and the insurer.

How much does Acthar Gel cost without insurance? A single 5-mL vial typically costs tens of thousands of dollars. Always explore manufacturer assistance programs and work with specialty pharmacies familiar with financial assistance options.

For complex cases requiring detailed appeals strategy, Counterforce Health provides comprehensive support in analyzing payer policies and crafting evidence-based responses that maximize approval chances.

Checklist: What to Gather Before You Start

  • BCBSM insurance card and member ID
  • Complete list of all prior medications tried for the condition
  • Medical records documenting diagnosis and treatment history
  • Laboratory results and diagnostic test reports
  • Names and contact information for all treating physicians
  • Any previous denial letters or EOBs
  • Current prescription and dosing information

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances, plan specifics, and current policies. Always consult with your healthcare provider and insurance company for guidance specific to your situation. Policies and procedures may change; verify current requirements with BCBSM and Michigan DIFS.

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